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Check Yourself: 6 Warning Signs You Shouldn't Ignore

By Lawrence Creswell | Sept. 24, 2018, 6:37 p.m. (ET)

Recognizing heart conditions.

The aerobic exercise of swimming, cycling and running provides many health benefits, particularly for the heart and cardiovascular system. 

Yet it can be an easy mistake to confuse or conflate fitness and health. Even the fittest triathlete isn’t immune to having — or developing — heart problems.

Here are six warning signs of potential heart troubles that triathletes shouldn’t ignore:

1. Chest pain or discomfort: The list of causes of chest pain is very long and includes many conditions that are completely unrelated to the heart. Some causes of chest pain that may masquerade as cardiac include injuries, even minor, to the chest or ribs; acid reflux disease of the stomach; costochondritis — an inflammation of the joints between the ribs and sternum and various disorders of the esophagus. 

Here, let’s set aside the various life-threatening causes of chest pain that often presents dramatically as an emergency: heart attack, or “acute myocardial infarction”; collapse of the lung(s), or “pneumothorax”; tears (dissection) of the aorta, the large blood vessel that carries blood away from the heart and pulmonary embolism (PE), a condition where blood clots form someplace in the body, dislodge and travel to the lungs.

More commonly, chest pain develops insidiously and can sneak up on the athlete. He or she can develop pain exertion and is relieved by rest. The level of exertion needed to produce the pain can sometimes be very reproducible. This presentation can be an indication of coronary artery disease (CAD), a build-up of plaque in the coronary arteries that supply the heart muscle itself. In its earliest stages, the pain can be very subtle, perhaps nothing more than a twinge. In its later stages, the pain can be crippling and may even limit normal exercise.

All of these presentations of chest pain, whether it is acute and severe or subtler, need to be evaluated by a physician to ensure safety. The manner of chest pain presentation is often insufficient information to make a proper diagnosis. The key to determining the cause is obtaining objective evidence via testing.

2. Shortness of breath: As athletes, we’ve all experienced shortness of breath and we’re probably accustomed to a certain degree of shortness of breath that accompanies a given level of exertion. What’s worrisome, though, is when there is some change to that pattern — when the shortness of breath is unexpectedly out of proportion to what is ordinarily expected.  That’s when concern should be raised.  

The most worrisome symptom may be shortness of breath that persists even after exercise stops or shortness of breath that occurs at rest.

Shortness of breath has many causes that are unrelated to the heart, including infections such as bronchitis or pneumonia; asthma (possibly made worse with exercise) and even chronic forms of pulmonary embolism.

But there are also several forms of heart disease that may be responsible, including: CAD, even in the absence of chest pain; heart valve problems (either narrowing or leakage) and various congenital problems that manifest in adulthood, such as “holes in the heart.” In healthy triathletes, the pulmonary system has a significant reserve, so often the cause for shortness of breath is the heart.

When you have unusual shortness of breath, get checked out.

3. Lightheadedness or blacking out: The medical term for sudden, unexpected loss of consciousness is “syncope,” but the grab bag of reported symptoms might include “blacking out,” “passing out,” or even just “lightheadedness” or “dizziness.” 

Again, there are many causes, including dehydration or unwanted side effects of various medications, among others. For endurance athletes, one common scenario is near-syncope or syncope at the end of a workout or race, when exercise is stopped abruptly without a period of cooling down. This is not usually a serious problem. Although scary, this situation often can be avoided just by remembering to have an appropriate cool-down after the workout or race. 

The most worrisome type of syncope occurs during exercise. Most frequently, this indicates a serious underlying medical problem — and is often related to the heart. All cases of syncope and near-syncope should be discussed with your doctor, but it is particularly important to be evaluated if you have syncope during exercise.

4. Fatigue: Like shortness of breath, all athletes become familiar with fatigue. Besides exercise, though, fatigue can be due to conditions such as depression, the unwanted side effects of various medications and anemia, among others. It’s also true that fatigue can be a non-specific symptom due to many forms of heart disease. Whenever there is a sudden change in the pattern of fatigue or when it persists for an excessively long time, it’s important to get evaluated.


5. Palpitations: Of these first five warning signs, palpitations — the feeling of an abnormally strong, fast, or irregular heartbeat that grabs your attention — is the most common among athletes. As many as 70 percent of adult athletes report this problem and there’s a long list of specific arrhythmias that may be responsible, ranging from “extra” beats originating in either the upper or lower chambers of the heart to intermittent or persistent arrhythmias (abnormal heart rhythms). However, most often palpitations by themselves are not concerning. If frequent palpitations bother you or if it is associated with other symptoms, it’s best to find out exactly what’s causing them.

6. Performance decreases: Here, we’re talking about any unexplained decrease in pace, endurance, or perhaps other measure of performance. Needless to say, there could be many causes, including poor nutrition or hydration, various illnesses or injuries, the distraction of life outside of sport, depression, or even, simply, aging. All of these possibilities deserve consideration. But it is also true that a performance decrement, in the absence of any of the other warning signs above, can be the only indication of a serious heart condition.

This is obviously a short list. But by paying attention to just these six warning signs, triathletes may give heed to many of the potentially serious heart-related conditions that could place themselves at risk.

Lawrence Creswell, MD, is an adult heart surgeon at the University of Mississippi Medical Center.  He is a triathlete and open water swimmer. Follow Dr. Creswell on Twitter at @athletesheart and at his blog at

Triathlon Medical Corner editor: Andrew Getzin, MD is the head team physician for USA triathlon. He is a USA Triathlon level I coach, multiple-time USA Triathlon All-American and has competed in Kona. He is a fellow of the American College of Sports Medicine.  Dr. Getzin is the medical director of Cayuga Medical Center Sports Medicine and Athletic Performance in Ithaca, NY, and the director of their shortness of breath in the athlete clinic,

The views expressed in this article are the opinion of the author and not necessarily the practices of USA Triathlon. Before starting any new diet or exercise program, you should check with your physician and/or coach.