To Swim or Not to Swim (During the Diagnostic Evaluation): Advising a Competitive Swimmer with Exertional Chest Pain

A 32-year-old male competitive swimmer with probable familial hyperlipidemia (with a Dutch Lipid Clinic Network score [DLCNS] of 6 points) presents with exertional chest pain. His family history is notable for sudden, unexplained death in his 38-year-old brother, presumed to be cardiac in nature. The family decided to pursue neither autopsy nor genetic testing. He is an elite sprint swimmer training for Olympic trials and describes brief episodes of exertional chest discomfort at peak exertion with swimming. The chest pain subsides with rest, and he cannot reproduce the chest pain with other physical activity, including dry-land training. In total, he trains approximately 30 hours per week, with 20 hours dedicated to swimming and 10 hours of dry weight lifting and light aerobic activity. He states that he has had elevated lipid levels for several years; recently, his low-density lipoprotein cholesterol (LDL-C) level was 218 mg/dL. His only medication is rosuvastatin 5 mg, which was started a few weeks earlier; he reports some muscle cramping since starting this medication. He does not endorse any previous or current smoking, alcohol, or illicit drug or supplement use.

His blood pressure (BP) is 140/85 mm Hg and heart rate is 54 bpm. His cardiac examination findings are unremarkable. He does not have any appreciable tendon xanthomas or xanthelasmas. An electrocardiogram (ECG) is performed (Figure 1). A transthoracic echocardiogram shows normal chamber sizes, normal biventricular function except for a reduced left ventricular (LV) global longitudinal strain (GLS) of -13.8%, normal diastolic function, and no significant valvular abnormalities.

Figure 1

Figure 1

Given his risk factors, including a family history of presumed sudden cardiac death (SCD) in his older brother, and exertional symptoms, the decision is made to pursue a coronary computed tomography angiogram (CCTA) to define his coronary anatomy and evaluate for any potential atherosclerotic burden.

He asks whether he can, in the interim, continue his high level of swimming and training to pursue his goal of qualifying for the Olympics. Both he and the clinician are aware that detraining over a few weeks while waiting for evaluation to conclude will be detrimental to his Olympic pursuit.

Which one of the following is the best management strategy for this patient?

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