A Matter of the Heart
Atrial Flutter, that is finally the answer, getting that answer and deciding what to do now that I have it is the real issue...
So, I have been a member of EN for just over 3 outseasons, I started racing Sprints and worked my way up to B2B (now IMNC) in 2014. I raced Raleigh 70.3 last year and this year. Intermittantly during all of that time, I have had runs of high HR on my HR monitor. It first happened in about 2011 when I was up all night on call at work and drank about 6 cups of java and then decided to go for my 6 mile run. About 1/2 a mile in, I got this feeling of being just REALLY tired so I walked about 40 feet and felt better and then went on and finished the run without a problem. When I synced my garmin, I got the message "Congratulations, New Max HR of 212" My HR had never been over 165 before that. So, I went to my primary care doc and had EKG, stress test, labs, and a real FTP test where they put you on the bike and make you breath through a tube so that they can measure your inhaled O2 and Exhaled CO2. All Normal. Referred to a Cardiologist where I had a 24 hour Holter monitor, month long cardiac event monitor (I ran 2 races wearing the thing but no recurrences), and an echocardiogram. All normal. His diagnosis was "Caffiene induced cardiac sensitivity" Proposed treatment : no caffiene.
I quit my daily 2 latte's and went to green tea. I kept training and didn't have any recurrences for about 6 months (OS 2013). Great, says I, Problem solved. Not so fast. I am a big guy (6'4" 210 lb) and it seems that the problem is related to heat dissipation in some way. I did OK during the outseason over the winter but as the spring came around, it happened a few more times. Same symptoms, Usually while running, I am going hard and try to push a bit harder and I just feel REALLY tired. Stop, feeling goes away, HR monitor tells the tale later. Since we were unable to capture the events on a cardiac monitor that would record a rhythm strip to diagnose the type of rhythm, We weren't sure exactly what we were treating so I just kept quiet about it and kept on training. During one sprint race in Charleston, it happened during the swim. I started out OK but got so I couldn't swim the freestyle stroke at all because I felt so anxious and out of breath and ended up doing the breast stroke for 700 yards. I initially thought it was just anxiety of the race and going out too hard but when I got on the bike, my HR was again over 200. I just soft pedaled a bit till it converted, then I felt normal and finished the race, no problem. It was a bit scary during the swim tho...
This was the year that I raced B2B full and by now it had happened 5 or 6 times total and I had gotten pretty good about knowing when I was going too hard and was likely to trigger an event so I decided to just concentrate on long and steady and lay off of the hard intervals which seemed more likely to trigger it. I also had a hamstring injury during that time which helped to remind me to go steady and not too hard in my training. I raced B2B full with no problems but I was very careful to go out slow on the swim and really tried to pace steady. Soon after that race, I moved to NC. We have Hills here and I started trying to ride with the local roadies for fun. I get dropped on the big hills but everyone loves to be behind me on the flats because I am pretty steady and make a big wind break. As I tried to move up to faster and faster groups to get better, I noticed that going really hard on big hills or really hot days, was more likely to cause an event to happen but I could still never get it to happen while I was wearing a real cardiac monitor. Got a new Cardiologist, new Stress test on the treadmill, no funny heart rate. All tests and labs normal. At Blue Ridge camp last year, I noticed that I did fine for day 1 and 2 but had an event on day 3 and day 4, always on a long climb. Each time, backed off or stopped and it went away. Emily Brinkley was kind enough to pull over with me on day 3 until it passed and we went on up the hill.
This spring, I was doing a Sufferfest video in the pain cave before Blue Ridge Camp and as I was getting near the end of a long interval and trying to make it to the end without dropping my power, it happened. This time it was a bit different because my HR stayed in the 115 range and was irregular which had never happened before. I drove to the ER and had the nurses run a strip on me and I took it over to my Primary care Doc (who rides with me). He called it Atrial Flutter. By this time, I was back in normal rhythm. I took the EKG to my Cardiologist (who was out of town). His nurse called the next day and told me to start a blood thinner. I reassured her that I had converted and was no longer in Flutter and made an appointment to see the cardiologist when he got back to town. We had some issues getting the appointment scheduled due to my surgery schedule and the long wait for appointments with him and I ended up going to 1 day of blue Ridge Camp and racing Raleigh 70.3 without seeing him. I just was careful not to go too hard and there was no problem. (Coach Patrick, that is why my HR on the Raleigh run went up and down so much, If I thought I was getting too high I had to back it off so as not to hit HR overdrive). After Raleigh, I made a concerted effort to try and resume harder intervals in my training and with the heat, the incidents became more frequent (4 or 5 times since Raleigh and twice in the last 10 days). Incidentally, I finally had my appointment with the Cardiologist and since I had not really discussed this with my wife too much in order not to worry her, I asked her to go along.
After a long discussion, the Cardiologist said the following : 1. Risk of sudden cardiac death is 80 times higher during strenuous exercise (in athletes in general, not just with my condition) 2. Risk of stroke is possible but low in my case since I usually convert quickly back to regular rhythm. 3. Cardiac Ablation has approx 1 in 1000 chance of death associated with the procedure. 4. Endurance athletes have an increased risk of Atrial fib compared to average folks and no one knows if Atrial Flutter changes that risk in my case. Which is to say that even if I get an ablation, I may get A Fib later on or the Flutter may recur. 5. There is a not insignificant risk of needing a pacemaker if they fry too much of your atrium. 6. Finally, he said : "Have a cardiac Ablation or avoid any exercise more strenuous than walking" As I mentioned in my Dashboard post, My wife took that one way and I took it completely the opposite. She wants a walking partner.
I feel that I have the ability to control this thing to a certain extent. If I don't really push it in the heat or accumulate too much chronic training load, it really is not likely to occur, I proved that in my IM build. My wife is deathly afraid of something bad happening with the ablation but I have had 2 close friends who have had it in the last year and they say it is not that big a deal. Unless things get worse with the episodes becoming more frequent, I may just keep on my maintainance training plan and see how things go during the OS while avoiding really hard intervals in the heat. I would be interested in anyone else's experience with this little inconvenience.
Comments
Sounds like your Cardiologist is spot on. You and I both know you will not be happy with just walking. Even if you someday, need a pacemaker. It's VERY rare anymore. The pacemaker will not prevent you from training. The funny thing with atrial fibrilation and flutter is that your heart is smart and lazy. This new highway that it has discovered is fast and easy. The more times it uses the highway the more times it's going to use the highway. You are seeing that pattern already. It's going to take less and less to put you into it too. Trying to control atrial flutter is like trying to grab a greased pig. Medications are marginally successful. The medications used will affect your HR and cardiac output. I think it's great that you are being offered an ablation instead of medications.
If your wife is worried. Let her know that you have more chance of going into A-fib, passing out and crashing your bike than the risk of the ablation. Post op recovery is simple. A couple of quiet days watching football. Wish you the best Cuz! Let us know what you decide please.
Ralph, I wish you the best, whichever path you take. I agree with Jacklyn though, it would be hard for me to "just walk" for the rest of my life, and I suspect it would be the same for you.
FYI, "Just walking" was never an option. I plan to continue training (just as I have for the past 3 years that this has been going on) with the exception of limiting my really "hard" intervals. I find that I have pretty good control of my exertion and can usually tell when I am getting close to the point where I am going to shift over into the crazy rhythm. So, I will just avoid those times as much as possible. When I am not in Flutter, the risk is negligible and since the episodes last for only a few seconds at a time and quickly convert, I feel pretty comfortable following it at this time.
At the point where it becomes more frequent or does not spontaneously convert, I will certainly consider an ablation. I just have to lay off of trying to keep up with the young bucks on the bike.
1. My episodes of irregular heart rate are more frequent in hot climates (summer).
2. They also become more frequent with increased training load and if I go hard for several days (like 3 day 250 mile rides) the last day I can essentially make it occur at will with exertion.
My new cardiologist examined my EKG and agreed that it was Atrial Flutter and suggested that, since the episodes were becoming more frequent, I go ahead with the Cardiac Ablation. That is a procedure where they use a catheter into your heart and zap the area of the atrium that is causing the irregular beats with electricity to make it stop causing the atypical beats. They did this in August and during the procedure, evidently I had a run of Atrial Fibrillation which is similar to Flutter but is a bit more complicated to fix. I started running in September, and had 2 or 3 runs of rapid, irregular heartbeats in the first month of resuming my training. Back to the Cardiologist. Since we have never captured the irregular rhythm except on the one EKG that showed Atrial Flutter, he suggested an implantable EKG monitor which is about the size of a really short #2 pencil. It keeps track of any atypical beats and transmits them to my Cardiologist at night while I sleep.
Since I got the monitor, I have only had 1 episode and it looks like it is probably A-Fib and is not acutely dangerous. After talking to my doctor and doing some research, I found this : https://www.velopress.com/books/the-haywire-heart/ . I found it very helpful in giving my information that I could use to try to structure my workouts in such a way as to limit the recurrence of the events. Some of the information in the book that I found helpful was :
1. In susceptible people, exercise volume can cause Atrial Fibrillation in the absence of the other common causes of the disorder.
2. The suggested treatment is decreasing training volume significantly.
3. Exercise that is less than 1 hour does not seem to be linked to the chronic inflammation that is thought to damage the heart and cause the Atrial Fibrillation.
At the end of the day, I am back where I started in an interesting way: I started doing Sprint Triathlons because of the varying types of exercises involved in order to avoid overuse injuries common when concentrating on just one sport. I got sucked in after that in the usual way with the "I could do an Olympic" which led to the "I could do a half ironman" and on to Beach to Battleship full distance in 2014. Finding time to train for a full distance race became harder so I did 70.3 races for a couple of years until my heart really started acting up. Now my doctor tells me that I can go pretty much as hard as I want but for shorter intervals. The plan is to see how the OS goes and then maybe go back to some sprint distance races in 2018. In the mean time, when I exercise now, I have to carry a little remote control that has a button that I am supposed to hit to mark the time if I have any future cardiac issues.
I am doing the OS workouts but keeping my total weekly volume below an hour a day. so far so good. I have a Half Marathon scheduled for May and I plan to ride with the team for a couple of days at Blue Ridge Camp but not for all 4 days due to the cumulative training load. We will see how things go from there. For folks who may be having cardiac issues with training, the book mentioned above is a good introduction to cardiac issues in the endurance athlete. Hope you never need it but if you do, it is full of useful information.