Stress tests give a good idea but they are far from perfect. If I had an abnormal stress test I would be exercising lightly with no interval training until I met with the cardiologist. You will need more tests to determine what is actually going on. Are you having symptoms? Chest discomfort, shortness of breath during exertion?

-I’m an exercise physiologist in stress testing.

No, as I said, no symptoms. Hence the doc said I shouldn't worry about changing anything for now.

Disclaimer first: MD but not a cardiologist. There are far more experienced MDs on the forum with cardiology specific knowledge.

I would not recommend you do any hard training at all whilst the cause of your ST depression is worked up.

My explanation won’t be as eloquent as the more cardiology focused MDs here, however…..ST depression is, in the majority of cases, secondary to ischaemia of your heart muscle. This ischaemia is essentially what most people know as a heart attack, this ischaemia can lead to infarction, which is the death of your heart muscle.

In a simplistic sense, the ischaemia is a result of an imbalance of the oxygen delivery to your heart muscle versus its requirements and is often caused by a narrowing in one or more of your coronary arteries.

Even though you may not have symptoms at present, this does not rule out significant underlying issues. In the face of it you may think it’s nothing to be worried about, but it is the consequences of that ischaemia and underlying processes that could cause all sorts of problems, some of them being potentially fatal.

Hence I would suggest it is very unwise to be doing anything that significant raises your heart rate, like intervals etc, some would go as far as saying avoid things like swimming on your own etc.

You really need to wait until you have had your cardiology review, and potentially more investigations, and await their clearance to return to normal training.

There will be much more eloquent replies almost certainly, I have chimed in because from where I was taught you don’t want to be doing those intervals etc at the moment.

[This ischaemia is essentially what most people know as a heart attack, this ischaemia can lead to infarction, which is the death of your heart muscle]

So as not to alarm the OP, ST depression can indicate ischaemia, what most people know as "angina" if they have symptoms.

It's infarction that most know as a "heart attack", which the OP doesn't have.

Thanks for the response, and yeah, I get it and know that ischemia is the most likely cause here, though there are other possibilities. It certainly does seem like the prudent thing to take it easy, so it is a little strange my doc is so chill about it.

There is always the benefit of hindsight, but you will see many stories on this forum alone of very fit individuals running into sudden, serious cardiac issues. Your doc is probably thinking, he is young and fit and gives himself a stress test everytime he goes training and hence likely thinks that it won’t be anything significant. In the flipside, for a variety of reasons, it can be this underlying fitness and adaptation that can mask more serious issues, along with the evidence around the long term negative consequences of some forms of training and racing because of the inflammatory responses in your vessels etc.

As I stated before, there are members of this forum who specialise in these issues and will reply far more eloquently than me, I just couldn’t sit here and not say something immediately in case you were going to head out for some interval training!

Thanks Amnesia, I really appreciate your responses. I think you're right about the doc perceiving me as being (relatively) young and healthy, indeed, he's remarked a bunch of times that I'm "doing great". But as you point out, being fit doesn't make me immune from heart issues (and my genetics don't bode well here) and may be masking potential issues.

Anyways, the doc's advice to "have at it" wasn't really sitting well with me, and I'm glad to have your response as a sober second thought here. I've been exceeding 180bpm on some of these intervals (max HR is >190) and the fact that I've been doing this possibly with ischemic heart disease is certainly concerning in retrospect. From what I can tell it's probably not prudent to even get up into Z2 at this point.

Bump in case anyone has experience with this test result

I never had a test. So, I can't speak to it specifically. However, I can certainly speak to being FINE until I wasn't.

At 51, 6 weeks after taking 3rd overall in a local 10k, I went out for a run on a Friday and began to experience angina. Sunday night I was in the cath lab with a 98% blocked LAD, and six other coronary arteries the least of which was over 92% blocked. 2 days later I had quintuple bypass surgery.

https://forum.slowtwitch.com/forum/?post=7150194

Appreciate your response Tom. I know stories like yours aren't uncommon, and it's sobering to know that you can be fit and feel fine and still get blindsided by this stuff.

Frustrating for me not to know what the cause of the ST depression is, and not even knowing when I'll get to talk to a cardiologist (the referral's been made but according to my doc "it might take a while"). For now I'm off training, which is a bummer because I was happy with my plan and where things were going. Now I'm resigned to not having any real athletic goals this year. And unfortunately for me, when I don't train, I don't sleep, so it's a grim existence right now.

I'm certainly familiar with the "blindsided" feeling.


I get it. Its scary, and its no joke.

Are you in the US? If not, please ignore....I can't speak to systems other than the USA. If you are in the US, I would NEVER wait for the receiving office to "do something". I would get the name of the referral doctor, and I would call them directly to confirm: 1) that they have received the referral and there aren't any issues with it, 2) WHEN they plan on getting an appt scheduled.

In 50-odd years, I can count the number of times that a "referral" has been executed without issue on one hand. Either:

1. The sending office doesn't really send the referral (in the US these are often transmitted via FAX machine).
2. The sending office doesn't include all the needed information
3. The receiving office didn't check their fax machine
4. The receiving office gave the fax to the wrong person
5. The receiving office person didn't do anything with it, and forgot about it.
6. The receiving office forgot to call you to let you know that an appt has been scheduled.
7. ...etc...

No one other than you has any real vested interest in ensuring that the appt gets made in a timely fashion.

To add a +1 to Tom's story... at 46 and chasing podiums I was also "fine", till I wasn't (but in my case it was being woken up in the ICU in Honolulu after 10 days and being told a crazy story of being found in the lava fields in the middle of the road in cardiac arrest.) Zero warning signs... and I have been repeatedly told they wouldn't have found any even if I saw the doctor right before my event. I had zero known risk factors and my arteries all look great... except for one little spot in my upper LAD that got me. Extremely high LP(a) (which everyone should be testing for!) is my issue. So... to the OP... stop training till you get things figured out and listen to your body.

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Team Zoot

Just updating this thread in case anyone goes searching in the future and stumbles upon it.

I stopped exercise altogether until I could speak with a cardiologist. Took 6 weeks to get in. Did another round of tests (Myoview at rest and stressed). The diagnosis: silent ischemia resulting from exercise induced hypertension. The good news is no blockages. The bad news is my athletic career appears to be over. Doctor's orders are from here on out not to exceed 75% of age adjusted predicted max heart rate (note my actual max heart rate is 15 BPM higher than the model predicts, which the doctor says is irrelevant here). This works out to be about 10 BPM below where my zone 2 starts, and it feels ridiculous.

Anyways, as I had zero symptoms it's lucky I went in for tests. So another example of why it's good to go out and get tested even if you think everything's fine.

I'm glad you got checked, and caught it before something even more serious happened. The diagnosis sucks, but...you are here.

Note if youre into the Facebook thing.... There is a group on there for "us"... Cardiac Athletes. Lots of fellow athletes from around the globe of all abilities. A few of "us" from ST are there also.

Thanks for sharing, is there a way to reduce the exercise induced hypertension to more normal levels so that you can continue doing sports while preventing any heart damage?

So my resting blood pressure has been high, not quite at the level that my family doctor thought medication was necessary, but the cardiologist thinks it's time (I wore a 24 hour monitor). So the plan now is to see how the meds take. At some point I may set up my BP monitor next to the trainer and monitor blood pressure while I ride the trainer, and see how the BP responds to increasing heart rate.

Yeah, I have a wife and three kids, so as crappy as the news was, it's way more important that I'm here for as long as possible.

Many folks have exercise induced hypertension (EIH). My understanding is that is a type of "masked" hypertension and it is not benign. It does make sense that EIH could have a greater negative impact on endurance athletes as they will spend a lot more time at high blood pressures and cause more strain to the cardiovascular system. I read somewhere someone trying to find a link between EIH and AF in endurance athletes.

Fingers crossed that the meds can reduce the EIH and go back to normal training.

Would love to read dtoce's take on this.

Consider a second opinion.


For the record, EKG's are good for telling if a patient is actively having a heart attack. I give lectures to students on reading EKG's and explain that when a coronary artery becomes totally blocked, as in an MI, the normal EKG changes that occur over the course of minutes to an hour include: flattening of the T wave, then ST depression, then significant ST elevation-usually in multiple leads.

As a screening test for CAD, the EKG is not a great test. An exercise ekg, aka a 'stress test' is ok but still not perfect (Overview of Exercise Stress Testing - PMC (nih.gov) with a sensitivity of ~70% and a specificity of ~85%. Imaging can be added like nuclear imaging (MIBI) or echo and increase the results but still not perfect. (Introduction to exercise stress testing (treadmill test, exercise ECG) – Cardiovascular Education (ecgwaves.com). Stress testing is a risk test which tells about physiology-ie if the heart is struggling for it's own blood and oxygen supply and the doctor can see if there are symptoms that occur with activity.

As I've said before, coronary artery calcium screening can tell if there is ANY cad/plaque there and help with risk assessment and tell how aggressively to treat the LDL cholesterol. Cardiac cath is diagnostic but coronary artery CTA is pretty darn close as an anatomic test.

EKG changes can also occur from microvascular angina where there is not significant blockages but there are EKG changes of ischemia and med Rx can help with this. There can also be changes from significant elevations in the BP affecting the heart but Rx is directed at the BP rather than anti-ischemic meds.


Long term Rx is then decided.


Good luck-

Obviously listen to your doctor.
I have 20 plus years of stress test experience. The depression on it's own is probably not significant. If the images were normal and you had no symptoms, you're probably fine. I had a stress echo years ago myself and had 3mm depression with normal images and I'm not concerned at all. Hypertension with stress can cause depression so check the report and see if your blood pressure went up.

If your nuc stress test was normal, it seems silly to say your career is over. The nuc has an over 99 percent negative predictive value. See someone else.

Yes, BP went way up (over 200 in both stress tests). I believe it was this hypertensive response to exercise that was the main concern, and, intuitively, it doesn't seem like a good idea to go on long sustained rides where my blood pressure is north of 200 for hours at a time. So I think ideally we'd be looking for a way to deal with the exercise-induced hypertension - we'll see what effect the meds (Azilsartan) have on this.

I was just coming on here to tell you the same as dtoce, get a 2nd opinion, and from a heart doc that understands the athlete heart. the red flag for me in your description that perhaps your guys is not fully up to speed, was the fact he told you to ignore your own HR max and go with the 40 year old outdated chart that is just an average of the entire population..Guys that dont understand that one simple thing, well I would not trust their advice very far at all.

there are so many anomalies that athletes have that are "normal" for us that the general doc population just dont understand, or care to. Most will treat you like the general population that comes in, and often you get really bad advice. Not saying what you got was bad, I would just call it suspect until I got info from someone like Dale, or like my long time heart doc that does understand the athlete heart and its proclovities..

It is not that uncommon for blood pressure to go that high in a stress test and probably not a reason to go on meds. Again, mine went much higher and I’m not worried all. Please see a different cardiologist. With normal images, your test would be considered a low risk study without symptoms. Even with depression and htn.