Sudden cardiac death. What is the risk? What can I do?
Obviously spurred on by Chris and the desire not to lose any other friends here or elsewhere and to live long enough to be a burden on my children. I hope the other Docs and medical folks in the group will chime in.
I spent some time scouring pubmed for info on sudden death in athletes and ways that have been suggested for prevention.
The overall risk appears to be about 1 in 200,000 (or 5 per million). Of all reported episodes 90% are in men and 10% in women. Under age 35, the majority of episodes are related to congenital heart abnormalities, while over-35 most are related to atherosclerotic disease in the coronary arteries. In the over-35 category 80% of cases are atherosclerotic/ischemic vs 20% which are presumptively a primary cardiac arrythymia. So far no universally accepted protocol exists to effectively screen athletes to find out who is at risk. Several European countries mandate EKG as a screening tool and it has been advocated for in the US by some. Proponents point out that the positivity rate in otherwise asymptomatic groups is 2.6%, while opponents note that the rate of sudden death hasn't fallen in countries that have implemented the screening (e.g. in Israel which adopted this measure in 2009, the rate is slightly higher after the screening process). So take home points, given what amounts to a real lack of meaningful scientific exploration into this area.
A baseline EKG may be helpful, though a normal one is not a bullet proof guarantee. FWIW, my EKG is normal.
Since most cases are related to coronary artery blockage in the Age Group athlete population, taking steps to optimize your lipid profile should be job one. My LDL is sky high and my total cholesterol is too high too. Not borderline high, big time MI high. As discussed in the vegetarian thread, I am deploying a veggie approach to slay this demon right now, but if the numbers don't respond I'll go on a statin or try paleo, or whatever. Gotta get it down though. Some have advocated a daily aspirin or taking a baby aspirin the day of a big race. The data are out on this approach though. It may sound obvious, but any chest pain at all (or jaw or arm pain) needs to be checked out PDQ.
For victims that didn't have atherosclerotic blockage, the likely culprit is a primary arrythymia. In this situation the heart generates a couple of extra beats (we all have these from time to time and most are of no consequence) that trigger a catastrophic cascade ending on ventricular fibrillation. Sort of like a heart seizure. It has been suggested that certain substances may increase the risk of this phenomenon, among them high doses of caffeine, antihistimines, NSAIDS, hypokalemia (low potassium), and of all things grapefruit. Avoid these before a race. I love coffee, particularly sipping a hot cup on the way to the IM swim start, but now its decaf.
Other types of sudden death. The heart isn't the only thing that can go suddenly. Cerebral (brain aneurysm) rupture has an immediate 50% mortality rate. At present we don't routinely screen for these (though they are estimated to be present in up to 2% of the population) in everyone, but if you do have a family history then you should at least consider a CT-Angiogram or MR-Angiogram for screening. The lungs can also get you with a sudden pulmonary embolus. Usually these arise from a deep venous thrombosus in the legs which breaks off and occludes blood supply to the lungs. A large embolus can be instantly fatal. We are most at risk for this when we travel to and from events. Avoid sitting for long periods of time in the car or on a plane without moving about. Particularly after a vigorous race. A variety of athletes (recently Serena Williams) have suffered from this. Compression garments may or may not be helpful and are clearly not a cure all.
I plan to win my AG at LP in 2067 and go to Kona in the M95-99 group. I hope to have to outkick all of you at the finish to do it.
Comments
Background: I am an MD and faculty neurosurgeon at the University of Rochester.
And I agree with Kevin's advice and think you did a nice job researching the topic. Hope you get the cholesterol profile you are looking for soon!
@Jeff. Oh how right you are. I just got up from a conversation here in the surgeon's lounge with somone with an obscene BMI (I really can't see how he can even get to the OR table) about how Chris' death proves that exercise isn't a good idea. I responded with exactly the points you make, an athlete's longevity is overall much longer as is their functional survival (ability to live independently into old age). Paradoxically the risk of sudden death during exercise though is higher as you mention (though still really quite low, far below the risks from auto accidents, etc).
Thanks for starting this thread will be very interesting to follow.
Nothing to add but short story. Reference PE.
Couple years ago my girlfriend had rotator cuff surgery. A week later at the follow up with doc , everything is good , she is about to be let go , and doc says anything else? She says yeah got a little pain in my back , thought nothing of it since you sleep sitting upright in a chair with the sling on your arm. Doc says you just bought yourself a trip to the emergency room , do not pass go , and go straight to the hospital. She had a PE . They don't take those lightly and was in hospital for a few days. Recent surgeries , sitting , and birth control are some of the causes. They took her off the pill immediately even though the cause was most likely the surgery. I immediately went for a vasecotmy LOL. One of the things I learned about PE's is correct me if I am wrong , the clot usually starts in the leg, usually gets caught in the lungs like a filter, if not they usually get caught in the heart?, but alot of people have holes in there heart (usually you dont know and is not a problem) but if you do the clot can then pass through and make it to your brain!
Kevin, Thanks for taking the time to do put up the info. Any thoughts on the The Running Doc's piece, "Steps to Avoid Sudden Collapse." Cliff Notes below.
Our study should put more science into our recommendation.
In the meantime, as I've said repeatedly, we continue to advise the following on race day:
1. Take a baby aspirin (81mg) the morning of the event.
2. Limit caffeine that morning to less than 200 mg.
3. Take the last mile like the previous without a fast sprint.
Personally, I developed an Afib last year. At first I didn't even know what it was, but I know now I could have easily stroked. And, yes, all the cardiologists say my ultra endurance events surely played a role. The final trigger seemed to be my husband's near fatal bike accident. Two weeks after the crash, the afib began.
Anyway, a cardiac ablation in September has set things right. I am free of afib and off all meds. My electrophysiologist gave me the green light to "do what I love." My regular cardiologist OTOH, while a huge fan of me doing traithlon, thinks Oly distances provide " a challenge that is far safer for everyone." Ironman, she continues, "not so much."
That said, I am registered for FL 2012. I am figuring out what to do, and will give it time. Chris's death certainly puts this is neon for me.
Also, if anyone has questions about afib and my story, and if I can be of help to you, please don't hesitate to ask.
@Kevin That's appaling a physician would say that particularly a chest guy. WTH?
@Linda So glad to hear that. Lots of endurance athletes seem to be prone to AFib. Happy to hear you are better and racing again!
@George, yes. I see plenty of younger people at the Heart Hospital 40's-50's S/P MI who are grossly obese but everyone seems to expect those I guess. We tend to focus more on the younger, fitter people who experience an event. I guess those are unexpected and more distressing to us.
@Linda. I would agree to limit caffeine intake. Not really any evidence that high intake is helpful in terms of performance. It can definitely induce palpitations in those susceptible. Avoiding sprinting at the end I think is a dubious recommendation (though I suspect Chris was going hard that last quarter so I must admit a lot reticence to come down too hard against this recommendation.) Its a recommendation that sort of sounds good, but not really sure that it is the magic trigger (i.e. if I am averaging say 160bpm for most of the race and then kick it up to 170bpm for a short stretch at the end, how risky really is that? vs if I had just stayed at 160bpm?) I think the relative risk increase of the sprint has got to be pretty small vs just the risk of doing the event at all.
I think the most controversial would be the aspirin recommendation. Right now, I believe ASA is only recommended on a daily basis for patients in those age groups who are at a moderate to increased risk of cardiovascular disease, not for generally healthy patients. There are set thresholds in terms of risk for each 10-year age increment based on heart attack calculators such as from the Framingham study. In my case, my risk of an MI based on my numbers (Ht, Wt, Blood Pressure, Cholesterol, etc) is 2% over 10-years. The threshold for ASA therapy would be a risk of 4% so ASA isn't recommended for me even though my Cholesterol/LDL level is high. The reason is that daily ASA therapy also carries with it an increased risk of intracranial hemorrhage and GI bleeding. So for me, right now, according to the Family Practice guidelines as I understand them (and as reviewed with my PCP, even though I am a doc, I still go see mine yearly) means the risk of daily aspirin therapy for me outweighs any benefits. I think this is the take home message folks should review with their doctors before embarking on an aspirin a day as the article suggests.
The person is a nice guy. He has struggled with weight and I know he knows the truth. Sometimes folks have to justify a bad situation to themselves to get by.
@Kevin I think most studies show 3-5 mg/kg of caffeine helped performance. Any higher has not really shown to benefit. WADA used to ban caffeine in high doses (>12 mcg/ml) but I think they overturned the ban in 2004. I recall that doses that high were not shown to enhance performance but clearly some athletes thought they did...
George can probably comment on this as he is a PharmD.
Most marathon deaths (or at least a disproportionate number) occur very close to the finish line. To suggest that we should look at participation in marathon and decide that it's a low risk and normally distributed is faulty logic. There is absoultely some elevated risk profile for some (all?) of us, and it has something to do with the unique set of circumstances of the last mile or so in an event like that.
I don't know what drives that risk, or what to do to mitigate it. But to say that it's as safe as driving a car, that's hiding your head in the sand. Chris was the picture of health on Sunday morning when the starting gun went off.
As Twain said, "there are lies, damn lies, and statistics". Hide behind them at your own risk.
I run cardiac testing at a heart hospital in Indy, and have commented on this in the past. I am not convinced that any manner of screening test (ECG, echo, stress test), applied to a low risk group of people (athletes) can reduce the incidence of sudden cardiac death in adults. As stated above, sudden death in adults is most commonly due to underlying atherosclerotic disease. It typically occurs when a minor plaque ruptures, and clot forms to rapidly occlude blood flow. Stress testing cannot detect plaque that is not obstructive, even though this "soft plaque" can be vulnerable to rupture. All we can really do is work on the things that contribute to plaque formation (high cholesterol, tobacco, high blood pressure, and unfavorable genes) and pay attention to symptoms. As for aspirin use, I agree that it is indicated in people at risk for plaque formation, but it would be hard to prove that it makes a difference in a low risk group of people like athletes. It's a tragic loss, but maybe not one that could have been prevented. If you want to do something, support his family and learn CPR.
Tim--
Her point was multi-fold. She was not only looking at the stress of the ONE DAY, but the OVERALL stress of training for long endurance events. Training for shorter events with intensity she claims is a lot less risky than the ultra-endurance world. Going fast is fine. Going fast is good for you within reason (proper rest and recovery, blah, blah). Putting it out there in a race lasting 1-2, maaaaybe up to 3 hours is fine.
She thinks IM and the like are way too in terms of much stress on the heart and inflammation that often results in arrythmias, afib, coronary calcium, and possible fatalities. She warned me of "idealizing inflammatory activities that threaten your life." That's what she said. Don't get her started on people who go from IM to marathon to HIM to century rides and back again. She also talked a lot about :
I'm not a cardiologist to say the least, but just reporting what I have been through and what my doc said. Hell, look at me. I'm not sure I can walk away either. That said, I am rethinking. This ultra-distance stuff is, by it's nature, unbalanced. Anything out of balance spells trouble. It is not necessarily the healthiest thing you can do, yet we convince ourselves that this fitness secures great health. I dunno. Big questions here.
Perhaps there are just too many unknowns at this point. I will say that without something like Ironman and HIM races to get me motivated to train hard and get in shape, I would be much worse off, physically, than I am now. And that can't be good.
My athlete/MD $0.02
@Tim: yes generally DVT's most commonly form in the lower leg, but any limb that is not in use has potential and even in some of the larger veins too. It's possible that while in the shoulder sling, that a clot formed in the immobilized arm. The lung is an awesome filter for lots of stuff, but the problem is when its big and then affects flow behind it from going forward and causes injury to the lung tissue. When there is a hole in the heart (20-30% of the population have a hole between the upper chambers at autopsy) the clot (or air bubble or bacteria or whatever) can bypass the lungs and go whereever: brain (stroke), gut, leg, arm, etc. Those with atrial fibrillation can generate clots in the fibrillating atria (upper heart chamber) and can take off and cause the same havoc.
I can see the rationale behind limiting caffeine. Years ago in my paramedic days, we used to give one of our colleagues a cup of coffee and hook him up to the EKG. He was so sensitive, the number of atrial and ventricular beats was better than Dubin's book (dating myself?) could ever provide. However, for the caffeine dependent, there is a mood issue too. Endorphins may run strong, but caffeine headaches/dysphoria from withdrawl can be miserable too. It probably is a good reminder that electrolyte intake is important for good cardiac muscle function, not just skeletal muscle function
I would agree with Richard that testing a low risk group would turn out very very few true positives, and a great deal of time (and money) would be spent chasing down false positives. This would expose those people to the risks of further invasive testing or unneccessarily limit their lives to confirm that is was in fact nothing there.
Endurance events cause alot of muscle stress and some of the markers we have for liver, cardiac, and liver injury also exist in skeletal muscle (AST, ALT, CK) and will be elevated after these events. In med school path class we ran a broad panel of labs on everyone in class to see the range of "normal" in a seemingly "normal" population. Well, we did this the monday after Wildflower where a handfull of classmates participated. As the results came in, the lab called the professors with the off the wall results who promptly called all the students to make sure they were okay and not in fulminant liver failure!
Jim--
Cardiomyopathy means "heart muscle disease," and is the the deterioration of the function of the myocardium (i.e., the heart muscle itself). As I understand what she said, the constant revving of the heart rate is the number one cause of heart muscle damage without other risk factors coming into play like heart attack or ischemic issues (decrease of blood supply caused by constriction or obstruction). The medical establishment does not understand why entirely, but she said theassociation between tachycardia and cardiomyopathy has been recognized for some time.
Seriously, if a doc can explain better please do. I just try to listen intently to her advice, take notes, and pass it on in the spirit that it might help.
Are these stories more common? Or is it just the internet and we more connected? Im not sure but it's really making me rethink my approach to athletics and my health.
To the question of "what can I do?" Well from what I am gathering here by some of the smart Medical folks is that regardless of fitness lifestyle or couch potato life style a person still might just be born with a heart issue resulting in sudden and early death. One thing you can honestly do for your family is to get your afairs in order to ensure your family is going to be ok if you die suddenly at a young age. There are a lot of healthy folks in EN who would probably qualify for life insurance. If you don't have it, you should probably get some. You can get a lot of covereage for a Term policy. If you don't have a will you should probably get one (me included). When I was in the army before we deployed they made sure every single one of us had these two things in place before we got on the plane.
I know it might sound in poor taste to mention those two things to some people but I have seen them make a difference. Dad past away at 63, life insurance made a difference to my mom. A good friend of mine was killed in Iraq and his 32 year old Widow suffered greatly. Financial security helped ease that pain a bit.
I will keep reading this thread for sure and Hope my comments aren't taken in bad taste or "wrong topic"... my mind is spinning..
Patrick, I believe you hit it on the head. Plane crashes are very rare, and so we don't think about getting on the plane. Endurance sport deaths are very rare, and so we never think about it. The NYT article suggesting baby aspirin, limiting caffeine, and not sprinting to the finish seem to me to be a reasonable approach to control the things you can control. To the OP who suggested that not kicking at the end would take away the joy, I'd ask what the risk/reward of that kick is. 10-20 seconds on a finish time vs. an elevated risk of sudden death (by some unknown factor)? I know how I feel about it...
At the end of the day, we all need to decide whether or not the 1/50,000 risk is worth taking. I don't have the foggiest idea how I feel about that right now for me and my family, and need the perspective of time to figure that out.
I never had the chance to meet Chris in person, but I read his posts in the forum and you could tell that he was one of the "good guys".
I raced the Ironman California (when it was a full Ironman) in Oceanside. An athlete named Perry Redina was competing and lost control of his bike and crashed and was killed. I rode past him after the paramedics has put a tarp over him. I got to thinking that he woke up that morning excited because this was going to be a special day in his life. He had trained for months for this very day. Perry did not know that this would be his last day. I had a lot of time to reflect during the bike and run portions of the race after word has spread of his death. This could be MY last day on earth. I try to think that everyday. Some people think of that as morbid, but as the book Tuesdays With Morey tells us, once you accept death, then you can really live.
Getting back to the medical advice. I remember a sports physician friend of mine who told me that old failing hearts showed a lot of PVCs (Premature Ventricular Contractions) on their EKGs. If you ever taken CPR or studied EKGs it means that there are extra beats in the heart that don't allow for effecient blood flow. Interestingly, hearts of world class athletes also showed PVCs. It appeared to be an indication of very heathly hearts as well as very sick hearts. The bottom line in my world is that you can improve your odds by lifestyle choices as far as longevity. There are things that you can change and risk factors that you have no control over. But most of us in EN are probably more concerned with quality of life issues. Education is the first step and a forum like this is very helpful. But knowledge by itself is not enough, because if it was, there would not be overweight and smoking cardiologists. Action must be taken on that knowledge.
The age spectrum in EN is all over the place. In my personal experience, I never gave one thought to my own mortality until I reached my late 30s. Until then I was invincible. Also, death had not reached my immediate family. Once into middle age, death became more of a occurence with family and friends. The standard joke is that you know that you are starting to get older when you start to attend more funerals than weddings. Everyone has their ways to grieve and reflect on death. I would just tell you to make each and every day special.
P,
I posted a thread similar to this a few months back after the deaths in the NYC Tri. My wife gets freaked out about deaths at endurance events. She questions why I do these things every time she hears about one. Often I can brush it off if I find out the person was inexperienced, out of shape, real old, etc. I waited until Monday to tell her that one of the fatalities in the Philly marathon was a teammate of mine and he was in the prime of his life and in amazing shape. I had no excuses. I couldn't brush away the fact my wife would see this in one way and one way only - what's different between Chris and myself and if it could happen to him then it could happen to me. Forget my wife for a second -- I couldn't help but fixate on that same issue.
The situation was only made worse with registration for IMAZ opening that same day. It took me another day to tell her I signed up for that. Her reaction - "Didn't one of your teammates just drop dead doing that?" I tried to explain that a) Chris was a much faster runner than myself and probably knew how to enter the suffer zone in a way I can't and don't want to fathom, b) the Ironman marathon is done at a pace already governed by the 114.4 miles already done in the water and on the road. In one ear and out the other, I'm sure.
I made a very strategic decision on my part to not do any triathlons during the summer next year. I don't want to race in it. I don't want to train in it. That's hard to do in Texas since there's a ton of local races in June/July/August. I suffered through a couple of races this summer in which the heat made the run extremely difficult. There were training runs that were excruciating. Running when it's 100+ degrees out is probably playing a little too much Russian Roulette. Eventually the round is going to go off. I just need to limit my exposure to it.
I'm going to sit back and reevaluate things for awhile. I know it's a bit of a knee-jerk reaction but I can't shake the thought of what happened to Chris could happen to me. I know the odds of that happening are slim to none but I'm sure Chris thought the same. It's hard not to look in a mirror and see Chirs. I'm 41 so we're basically the same age. I have a wife and a 6 year old. I "almost" play in the same sandbox when it comes to ability. I have made tremendous gains in my training and racing the last two years and want to continue getting faster and faster. That was going to be done through intense work and motivation. I have certain goals I'd like to reach. Is it all worth it? No offense to what Dan S. posted but I don't want to be that guy that drops dead during some meaningless race and have people say "he checked out doing something he loved." That's bullshit. You know what I love more than racing? Being alive. Unless it's your job, dropping dead while swimming, biking, running or skydiving, running with the bulls, whatever is just plain silly. It's a waste. I'm pretty damn certain that Chris would rather have another 40 years with his family than check out trying to run a 3:05 marathon. It just seems so pointless in the grand scheme of things. Yes, I can say that with the benefit of hindsight and yes, it's unfair. I know we can't pick and choose when we go.
The FBI requires all Special Agents to have a full physical every other year. The treadmill stress testing is added after 40. My physicals have been nothing but stellar. I'm doing all the right things. I just hope it's enough.