Asthma and Patellofemoral Pain Syndrome

As a child, I suffered badly through hay fever, which turned into asthma when I was around twelve years old.  After an incident when I blacked out, I was prescribed two inhalers and told not to take part in school sports.  I was not particularly good at team sports, so was happy to avoid the football, but I did miss the cross country running.  I can’t remember how I discovered this, but I was able to cycle without difficulty.  Eventually, I noticed that during exercise I had no hay fever or asthma symptoms.  I was able to come off the medication and the following year, I joined the local bike club.  As I grew older, my asthma never resurfaced, except for an tendency to persistent upper respiratory tract infections; although this only occured at times when I had allowed my fitness levels to fall.

By 1990, I was cycling thousands of miles per year, as well as making regular visits to the gym, swimming, playing squash and running.  I was extremely fit and healthy, eating well and totally alcohol-free.  Several times a week, I used to run six miles or longer and completed a couple of half marathons.

At the time, I was working for a company who were exploiting a new business opportunity in Ireland.  They had made a decision to sponsor the following year’s Dublin marathon.  One of the directors was a reasonable runner and offered several of us the chance to run the marathon as a works team.  I was very enthusiastic and started to gradually increase my running in preparation.  All was good for a month or so, my mileage was steadily increasing, as was my average speed. 

Eventually, I started to feel a little pain in my knee.  I eased off the exercise a little, but the pain was getting worse.  I took a few days break, but the pain was still increasing, so I made a doctor’s appointment.  The doctor asked me if I took regular exercise and how much over the last week. He seemed shocked at my answer: three days in the gym, 150 miles cycling, 24 miles jogging, 64 lengths of the local pool and two games of squash. “And you’re surprised you’re having problems?”, he responded.  His advice was to stop exercising entirely and take a few Ibuprofen, which seemed to make sense.

Unfortunately, this put me into a downward spiral of discomfort and pain and I ended up back at the surgery three weeks later.  Luckily, this time I saw a locum with a specific interest in sports injuries.  He considered that my sudden increase in running and reduction in cycling had allowed my quadriceps to atrophy resulting in my kneecap wobbling in its guide and causing inflammation.  His recommendation was that I go back to the gym and concentrate on leg extensions and also return to cycling.  This was surprisingly successful and had me back to normal within a fortnight.  I never jogged again. 

Ten years later, I was at the Glastonbury festival. I was kneeling in the tent cooking some food.  A few hours later, I had incredible pain in my left knee which felt the same as my previous exercise induced problems.  Luckily, I recovered from this the next day.  Over the last fifteen years, I have had just a few mild instances of this, always connected to kneeling, but nothing that has caused problems over an extended period of time. 

In November, we had a lot of carpet replaced; two flights of stairs, a landing, three bedrooms and an office.   Prior to fitting, I had to remove all the old carpets and accessories.   This took a long time and involved a lot of kneeling.  The recovery then took a long time and involved a lot of paracetamol; ibuprofen would have been better, but I have since discovered it is not safe for those with arrhythmia.  I have also had a light but persistent productive cough, which I think is related to the relatively light level of exercise I have had since November.  My Garmin account has certainly noticed and informed me of a drop in my VO2 max.  I am now actively exercising while still being wary of the roads.

Overall, I seem to be in a position of dependency; if I stop cycling, I will develop knee problems and asthma. This is not a problem at this stage of my life, if anything it is a good excuse to get out on rides.  I am concerned about what will happen as I age; if something happens to prevent me exercising, will I fall into a spiral of pain, asthmatic and unable to walk?

New year update

Icy roads prevented me from exploiting my time off over the festive period, particularly as one of my clubmates managed to break his hip in an icy fall on Xmas eve.  I still to managed to hit 3068 miles this year, which is the most I have done since 2002. Veloviewer also includes 311 miles walking, which is also a record.

New Strava record

I have a new record on Strava.  I have just passed 3000 road miles for this year; this is a little short of the target on 3500 I gave myself and nothing compared to the mileage I achieved in the 80s (pre-GPS so officially it didn’t happen).  

I still have ten days left until the end of the year, so I will probably beat the number of total miles (including velodrome, rollers and family rides) which only stands at 3099 miles. This is nothing special for a club rider, but I think this is spectacular compared to the future I expected on diagnosis if AF.  

This time it really is the three yearly review

I set off for the hospital with an hour to spare for a 40 minute journey, forgetting that today was the first shopping day after lockdown.  Sheffield traffic was mad, but I still arrived with time to spare.

The meeting was fast and efficient as usual: ECG, HR 70, BP (131/86) and weight 83.4 Kg.  The nurse was very happy with these, although I was less happy about the last two.  The consultant turned up, looked at the ECG, seemed very pleased, thanked me for my help with the research project. 

https://clinicaltrials.gov/ct2/show/NCT02695277

I asked how it was going.  Apparently, significantly fewer numbers than expected were recruited (at least in the UK, 15 instead of 45) and the completion worldwide has been delayed by Covid (a lot of research effort was diverted to the vaccine).  The finish date was expected to be November 2020, supposedly the date on which the last subject has their final interview.  In July when the last update was published, it was expected that recruitment of new subjects would take place which could push the trial back another few years.

In spite of this a preliminary analysis is being prepared which may suggest that the trial was overwhelmingly successful, if so, the trial will be stopped and the recommendations published.

Not the three yearly review

Yesterday I had an appointment with the cardiologist; last year he informed me that I would no longer need the annual halter monitor, ECG, blood tests etc, and that the last two years of the CEASE-AF study would be completed by telephone interview.  My staff were running two remote courses this day (one on Teams and one on Zoom) and I normally log in with the trainer prior to the course to ensure that the learners are able to access the system.  The trainer on the early course had a disastrous start, his system just would not work.  I ended up embroiled in his difficulties and missed the call from the doctor.

I picked up a voicemail message from him later, in which he appeared confused as to why he was calling me and said that he had asked his assistant to contact me over the next couple of days to make an appointment to come and see him.  I am sure I will get another phone consultation.

I am still getting a few readings of high stress from the Garmin, but these seem to have no bearing on whether or not I feel stressed.  I have also had one very high reading where I have appeared to be stressed during sleep (this was a possibility; it was the Sunday night before a difficult week).  I was going to ask the cardiologist whether I should take this information seriously.

My cycling is continuing to improve.  I am not consciously putting more effort in to it, I am keeping below the 165 HR and I am continuing to spin uphill rather than attack with power.  There is a steady improvement in my average speed.

I have been recording data since I bought a Garmin in June 2008.  This graph shows the average speed for each month in blue with a 12-monthly average trendline in red.  This prevents the higher (and faster) mileages in the summer months from artificially inflating the annual statistics. 

The graph holds relatively steady until around March 2015.  There is a slight downward trend, but this was mainly affected by increasing ride distances and group rides with slower friends.  I now know that Mar 2015 was the start of paroxysmal AF which slowly worsened until I entered persistent AF twelve months later.

My average speed dropped off a cliff at this point, but has been steadily improving since January 2018 after my recovery from the two ablations.  My current average speed on this graph is 15 mph and I think (hope) it is still rising.

A little wobble

I had managed to get through my period of slightly elevated drinking without any effects whatsoever.  This week, I was out teaching again so had a pint with my meal, it was a four hour journey to the venue, so I was ready to relax when I arrived.  The training was stressful, fifteen learners socially distanced on a course that normally relies on a lot of group work.  It was a long day; another four hour drive with a Burger King at the services half way back and a glass of wine when I arrived home. 

Later in the evening (22/10) I had a lot of ectopics, to the point where the Kardia gave me an AF diagnosis. 

It wasn’t AF, the beats were relatively regular, but with quite a few missing.  There were no other symptoms, but it was worrying nonetheless.  I took several readings over the next hour or so and had several “Normal” results, but with ectopics and one “Unclassified”. 

In the morning, the first trace I took 8a.m. had lots of missed beats and another diagnosis of “Possible AF”.  Again, there were no other symptoms.  Throughout the day there were several “Normal” and one “Unclassified”, but all showed ectopics.  On the next day everything was back to normal.  Not even a single ectopic.

In the lead up to this episode, my Garmin had recorded a few days of raised stress levels.  It normally averages around 20 on a fairly arbitrary scale, but from the 10th to 17th it was around 30 and, on the 18th and 19th, it jumped to 60 for no apparent reason. It has been normal since then, which is also odd, as I would have expected my stress to be highest on the day of the course and the later arrhythmia (22nd).  Normal is on the left, the high stress reading is on the right.  Note that it suggests I am incredibly stressed during sleep; I am certain that the readings were rogue. 

I am really confused; I don’t know whether it was the stress of work, a low level virus or even THE virus that caused the episode.  There are no after-effects and everything seems completely normal again now.

Alcohol

I have often discussed my love for alcohol and my inability to want to give up completely.  I know its bad for my AF (and my cycling) but I still want to enjoy it.  I try to log every drink I have and try to stay within the government recommended limits, but just over the last six months, I have been a bit lax with my counting and my intake has crept up a little. 

This does not appear to have given me any problems; my GGT is down at the high end of normal, my level of ectopics is lower than ever and I generally feel very well.  On the minus side, my blood pressure is slightly elevated.

I am also currently a little stressed; I am now working less from home and more back in our centres and hotel venues. There is still the threat of redundancy from the sale of the business which would not be a problem, but the organisation is also trying to negotiate down our generous redundancy terms.

I am currently off the bike due to a knee injury sustained removing carpets from the house.  My knees have been fairly fragile since marathon training in the 80s.  I did try a ride at the weekend, which was pain free while on the bike, but increased the pain I felt after I stopped.

I have decided to cut back drinking severely again, just a little wine at the weekend and I will try to edge myself gently back into exercise.

Average speed returning to normal?

I have always been obsessed with data manipulation and since 2008 when I returned to regular cycling after the children were less dependant on me, I have kept details of every ride.  I have logged distance, time, climb, max speed, and average/max HR.  The latter figures were useful in helping my AF diagnosis, but the others were just used as motivation.

After every ride I would log the data and then produce graphs of average speed, climbing, distance etc.  for the month, quarter and full year; this was only for road or trail rides, I logged rollers and velodrome rides separately.

Up until 2015, I was generally averaging 16 mph over a rolling 12 month period.  It then started to dip slightly to about 15.5mph although until I entered persistent AF in February 2016, I thought I was just starting to feel my age.  I continued to ride under the guidance of the cardiologist and my 12 month rolling average dropped to 12.9mph just after my first ablation in April 2017. 

Three months after my second ablation the average started to climb again, hitting 14mph in August 2018 and 14.5mph in July 2019.  I am now (September 2020) finally back to 15mph and can see further improvements daily. 

In the graph below, the blue line is each day’s average speed and the red is the average speed of all rides in the previous year.

Since my return to health, the key difference to my riding is my max HR.  Before I developed AF, my rides were at an average HR of 155, with a maximum in the high 170s (ramp tested maximum was 185).  In order not to place too much strain on my heart I am currently on a self-imposed maximum of 163, although it is usually less than 160, and my average is around 135. 

I am now wondering whether I was as fit as I thought before AF kicked in, and my high HR was not me working to my limits, but my compromised heart struggling to keep up with demand.

Stroke Risk and LAA Occlusion

I still post regularly on AF support forums giving updates on my progress; mainly the AF section of health unlocked https://healthunlocked.com/.  I think this is helpful to new sufferers, as most posts on there are about problems rather than solutions, possibly because “cured” members tend to drift away. I think it is also useful as my treatment is relatively rare in the UK; mini-maze with Left Atrial Appendage Occlusion by the Atriclip device.

Occasionally, I will be admonished by other members of the forum for not remaining on anticoagulants; the feeling is that the risk of stroke continues after NSR is returned and that there are possibly times when I could be in AF without realising it.

Today I found a reassuring video of a PPT presentation by Michael Hoskins of Emory University Hospital. https://wondrmedical.net/videos/Atrial-Fibrillation-Therapies-38BC74612

The presentation discussed a couple of medical trials: ProtectAF and Prevail.  Protect was to look at how the outcomes of LAAO compared with Warfarin.  Initially ProtectAF showed that post procedure stroke prevention was as good as warfarin, but there were issues with complications.  Prevail was designed to examine the safety aspects of LAAO after the original issues with ProtectAF came to light.  This research and the later entrants to protectAF showed that these had been resolved as surgical experience improved. 

The data after five years showed that LAAO was not inferior to warfarin for ischemic stroke, although there was a slight inferiority visible on the graph.  Importantly, it did show a great advantage with regard to haemorrhagic stroke and a large reduction in all case mortality.  A secondary finding was that ablations with LAAO were more effective and less likely to revert. LAAO has always been controversial, some cardiologists believing that it may have an as yet unknown function, this report concludes that the existence of the LAA contributes to the chances of developing AF.

Overall, this study gives me confidence that I made the correct choice and am happy to continue my drug free life.

LFT results

A few weeks ago I had my LFT test; unfortunately they forgot to do the GGT, which was the only one result that was out of normal range.  I was called back for a GGT test only and while looking for the result, I found some other results from back in 2006; these had been added to my patient record due to a change in the records policy at my GP. 

At the time of the tests, I was experiencing severe back pain that was eventually diagnosed as a gall bladder infection.  At my consultation with the Doctor, I specifically asked for liver tests as I was regularly drinking above guidance limits and the symptoms I was experiencing appeared similar to those of pancreatitis. 

The practice notes at the time gave GGT as 166 (the normal maximum is 61) which was accompanied by the note “Abnormal, speak to Doctor”.  I did speak and a raft of other tests were ordered, but the high GGT was not mentioned; I was told the liver was fine.   I had further tests over the next few months; the GGT was lowered, but this could have been due to stopping drinking over this time.

In October 2012 I was invited in for a health check.  Again, I specifically mentioned that I habitually exceeded guidance levels on alcohol, but no further tests were done.  The questionnaire decided that I was quite a fit individual and the advice given by the nurse was that “everything is OK, just carry on doing what you are doing”.

At the time of my AF diagnosis, I was subjected to many tests including liver function.  This was the first time I had been able to see the results and was very pleased to see that the majority were exceptionally good; as a cyclist I was particularly happy with the haemoglobin and haematocrit being practically at maximum.  The one outlier was GGT at 217.

The doctor was unconcerned, but I researched this and realised that high GGT with no other issues was generally related to alcohol.  I severely restricted my drinking, following government guidelines on units.  After a year of minimal drinking the level had dropped to 112.  At this point, I had the first ablation and stopped drinking completely. 

After another year, the reading was still at 71.  I resumed drinking, within government guidelines (with a few more lapses than intended) and am now still hovering between 60 and 70, the replacement for the forgotten test being 69.  

I am not convinced that this is 100% OK, but all the medical profession seem quite happy with it. I may be able to reduce it by another 10 by complete abstinence, but there is no guarantee of this. I enjoy my glass of alcohol, so I will continue in moderation.