MI:Journal

Valley View Hospital will be holding three community health fairs this spring, bringing blood tests, medical screening and education to various locations. There will also be two opportunities for an early blood predraw to get your blood results back before the health fair. A predraw allows you to ask questions about your results at the Heart Health Fair doctor’s information booth.

Health Fairs
(Blood tests, medical screenings and informational booths):
Roaring Fork High School (Carbondale)
Saturday, April 6, 2013, 7 a.m. to 11 a.m.
Coal Ridge High School (Silt/New Castle)
Saturday, April 13, 2013, 7 a.m. to 11 a.m.
Glenwood Medical Associates (Glenwood)
Saturday, April 27, 2013, 7 a.m. to 11 a.m.

Health information and testing is available to anyone 18 years of age or older. Optional blood chemistry analysis, including tests for cholesterol, cardiac risk, blood sugar, kidney and liver function are provided for a fee. Blood chemistry testing requires fasting 12 hours before screening; however, diabetics should not fast. No appointment needed.

Blood Draw $45,
Prostate Specific Antigen (PSA) $35,
Blood Count $20,
Colorectal Kit $15

For more information call 384-6651 or visit:

http://www.vvh.org/pages/p-lab-blood-results.php

Thank you to all who came out and Rode Your Hearts Out today in addition to your generosity. And especially to our Ride Leaders RB, TO, DJ, KA, ZM, MA, CK, JG, SG for his AED, Dad for his SAG support, and last but not least our aid station attendant TY! We couldn’t have pulled it off without you.

Join us for our 4th Annual Ride Your Heart Out, Tuesday July 3rd.  Ride leaves Paradise Bakery in Aspen at 9 am.  See the Maps below, download your waiver, bring it with you signed and Ride!!  Call Scott Kasin at 512-289-9662 with any questions.

Gary Albert, Rob Bordan, and Tom Ogden (r-l) MI Aware's Inaugural Ride Your Heart Out 2009

100 Km Route Map

50 Km Route Map

MI Aware Waiver

CW: It’s settled–Long-term extreme endurance exercise is not heart healthy

JUNE 6, 2012

My inbox lit up this week with links to mainstream media reports that extreme exercise causes heart damage.

Sure enough, a group of US researchers published an exhaustively complete review article on the Potential Adverse Cardiovascular Effects from Excessive Endurance Exercise. (Full text available.) Though published in the modestly circulated journal, Mayo Clinic Proceedings, this article makes a serious impact.

In this post I will attempt to recap–in my language—why these authors have garnered significant attention in the mainstream media. As I go through the ten topics addressed in the paper, I’ll report the findings and add in a typical naysayer’s view.

(I apologize in advance—this is a longer post than I like to write.)

Some basics:

This paper offered absolutely no new data. It was a review article—a really terrific one, but still a review. In fact, many of the studies cited have been previously discussed on this blog. Why the media buzz then? Perhaps it was the power of putting all the evidence together (including 68 scientific references) in one paper? Perhaps it was just that Yahoo news published the paper? Perhaps its appeal has something to do with non-exercisers reveling in the exposure of chinks in the armor of the super-fit. Hubris has this effect.

The review article was split into ten sections. I’ll call them chapters.

Chapter 1: Regular moderate exercise is beneficial:

The authors start smartly. They begin by citing the many studies that document the long-term benefits of modest amounts of regular exercise. Two studies in particular show a U-shaped pattern of benefit: that is, to get maximal health benefits, one must exercise enough, but not too much. This Taiwan Study of more than 400,000 patients published in the Lancet nicely demonstrates a leveling off of benefit after one hour per day of exercise. I won’t spend much time here because this is so obvious.

Chapter 2: Sudden Cardiac Death and Endurance Exercise:

In this section, the authors cite the recent NEJM article on the safety of marathon running. As previously noted on this blog, the risk of suffering cardiac arrest in a marathon is extremely low (1 in 100,000), and not changed with the increasing numbers of marathon participants. Triathletes have double this risk, mostly because of an increase in deaths during the open-water swim (for obvious reasons.)

Chapter 3: Animal Studies:

It’s no surprise that the authors led with the famous and elegant Marathon Rat study. This powerful study is worth a review: Canadian researchers studied two groups of rats. One group ran like crazed ultra-marathoners and the other group remained sedentary. The running rats developed enlargement of all four chambers of the heart, abnormal heart stiffness, an increase in heart scar tissue and an enhanced susceptibility to dangerous heart rhythm problems. Ouch.

Of course, the skeptics counter that this was a rat study, and therefore might not apply to humans. So noted.

Chapter 4: The Athlete’s Heart:

The authors nicely summarize what an “athletic heart” means. Here is their thought process: Long-term endurance exercise, especially chronic aerobic exercise, induces adaptations in the heart, including increases in right and left ventricle volumes and wall thickness, increases in the overall mass of the heart, and enlargement of both atria. The striking thing about these adaptive changes is that when they occur in normal people, they are thought to confer a bad prognosis. Which is it then? Bad or good? The authors go on to cite four studies supporting the idea that ‘athletic’ changes may not be entirely benign. One study even notes enlargement of the heart can persist long after de-conditioning.

Naysayers look at these reports and rightly point out that they are non-randomized look back studies of small groups of extreme athletes. Noted again.

Chapter 5: Biomarker Evidence with Extreme Exercise:

At least five studies confirm that up to 50% of marathon finishers show elevated levels of cardiac enzymes. You know, the same chemicals released during a heart attack.

The authors use the rest of this section to speculate on the significance of exercise-induced enzyme rises. Using phrases like, “this may reflect myocardial cell damage at sites of myocyte slippage,” it’s easy for a reader to take notice. Does exercise cause such violent slipping of heart cells so as to spill enzymes? For a blogger who has been on many a long run or ride, these are scary words.

To the authors’ credit, they admit to not knowing the significance of elevated enzymes post stressful exercise. Good for them.

Chapter 6: Extreme exercise and adverse structural remodeling of the heart:

This section details the scariest aspects of long-term exercise. Extreme exercisers might want to skip over the upcoming paragraphs.

Two important reminders: the human heart does not regenerate itself—scar remains scar—and, you only have one heart.

The authors set the tone well by telling us that intense exercise can increase the cardiac output from 5 liters per minute at rest to up to 25 liters per minute during exercise. Think about that for a minute—pumping 25 liters of blood per minute for a 12-hour Ironman! (Sorry for the hyperbole.)

Let’s look at a few of the studies that were reviewed. As I wrote about previously, this Australian study examined the immediate damage to the heart (particularly the right ventricle) after major endurance events. The sobering report had three major findings: 1) Athletes finishing major endurance tests had elevations of heart enzymes, and the amount of leak paralleled dysfunction of the right ventricle. 2) Longer duration events  predicted more right ventricular muscle weakness. 3) Scar was seen on MRI scans in 12.5% of athletes and was more likely to occur in longer events. The conclusion here was that extreme exercise can induce right ventricular abnormalities while largely sparing the LV. The only shred of good news was that in most (but not all) cases, the damage was transient.

Further implicating the right ventricle’s susceptibility, the review paper highlighted a study demonstrating a strong relationship between abnormal right ventricles seen on MRI scans with the presence of ventricular rhythm problems. More than half of athletes with ventricular rhythm issues had RV scarring.

Unfortunately, RV scarring is not the only exercise-induced structural change of the heart. Take this German study of 100 experienced marathoners that were compared with regular age-matched controls. Patchy scarring (on MRI scans) of the heart were seen in 12% of runners—three-fold more often than non-runners. The kicker here was that over 2 years of follow-up, marathoners had more coronary events than non-runners. Again, the review paper cites numerous other similar studies.

Skeptics will continue to emphasize the fact that these studies are small and non-randomized. Okay, I hear that. But the evidence is mounting.

Chapter 7: Extreme exercise and changes in the coronary arteries:

This section focuses on the well-established finding that marathon running increases the likelihood of having calcium deposits in the coronary arteries. It goes without saying that coronary arteries fare better when not hardened and stiffened by the presence of calcium. Most damning is this German study of marathon runners: not only did the runners have more calcium in their coronaries, but most remarkably, the supposedly extra-healthy runners experienced the same frequency of heart attacks as a group of patients with known heart disease! A similar study was presented at the ACC meeting in 2010, and was covered in this piece on theHeart.org.

Again, the counter argument centers on the lack of comparative studies done over the long-term.

Chapter 8: The Pathophysiology of extreme exercise:

Pathophysiology is medical speak for abnormal adaptations that occur with long-term exercise. In this section, the authors mostly speculate that extreme exercise causes heart damage by inducing excess inflammation. A few studies confirm the presence of high levels of chemical markers of inflammation in extreme exercisers. There’s not much else to say here other than many studies implicate excess inflammation as the mediator of heart damage from excess exercise.

Chapter Nine: Extreme exercise and electrical abnormalities:

I’ll keep it succinct. The data speak for itself. Long-term exercise results in a five-fold increase in the risk of developing atrial fibrillation. The authors cite twelve papers supporting this obvious truth.

AF isn’t the only arrhythmia seen in the super-fit. As supported by five studies, ventricular arrhythmias occur commonly in endurance athletes. It’s worth recalling the marathon rat study, which showed a greater susceptibility to arrhythmia induction in the running rats.

I witness these findings nearly every day. Skeptics can deny the association of excess exercise with arrhythmias–but they would be wrong.

Chapter 10: Risk assessment:

We simply do not have cost-feasible means to identify those exercisers who either suffer heart damage or are at risk of damage.

One potentially promising strategy might involve doing coronary calcium CT scans in highly selected marathon runners. I hesitate writing that last sentence because it’s pure speculation, formed in my head by a couple of tragic cases of marathon runners who suffered heart attacks and at cath were found to have rock hard coronary arteries.

The Mandrola take home:

Step back and look at the big picture here. When you lay out all ten chapters on a canvas, the picture takes shape. Your conclusion should be the same as the authors:

In some individuals, extreme exercise causes severe heart abnormalities.

Many questions remain. The dose of exercise that causes damage is unknown, as is an individual’s susceptibility to varying training loads. We don’t know the ideal exercise regimen, or if there is one. I know what is too little exercise; I know what is too much; but there’s a large space in between.

I’ll finish with the obvious…

Just like everything else in life, even exercise has an upper limit.

JMM

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Related posts:

CW: More bad news for the (extreme) endurance exerciser
CW: Believing the future will be better…is heart-healthy?
CW: Is the Ironman triathlon heart-healthy?
CW: That exercise has an upper limit makes perfect sense

Cholesterol Lecture
A follow-up to Valley View’s Community Health Fairs

Tuesday, May 15, 6:30 to 7:30 pm
3rd Floor Conference Room at Valley View Hospital
Dr. Greg Feinsinger will explain what your numbers mean, with an emphasis on heart attack, stroke and diabetes prevention. Bring your lab results from the Health Fair.

Brought to you by Valley View Hospital HealthQuest and Glenwood Medical Associates

Predraw Blood Draws only
Glenwood Springs Community Center
Wednesday March 7 and Wednesday March 21
6:30 to 10 a.m.   
 
Community Health Fairs 2012
(Blood tests, medical screenings and informational booths):
  
Coal Ridge High School (Silt/New Castle)
April 7, 2012, 7 a.m. to 11 a.m.
  
Roaring Fork High School (Carbondale)
April 14, 2012, 7 a.m. to 11 a.m.
 
Glenwood Medical Associates (Glenwood)
April 28, 2012, 7 a.m. to 11 a.m.
  

 
For more information call 384-6651 or 

http://www.vvh.org/pages/p-lab-blood-results.php 

DENVER (CBS4) – Chest pain is considered the hallmark symptom of a heart attack, but patients can also experience other kinds of pain, and in some cases, none at all. That’s especially true for women, and they can be missing the symptoms.

Researchers say younger women have a greater risk of dying from a heart attack. A new study in this week’s Journal of the American Medical Association indicates that may be because their warning signs are often very different.

Lalina Franklin was having neck and jaw pain. She had no idea she was on the verge of a severe heart attack .

“You think of some really bad pain in your chest and collapsing. I wasn’t having any pain at all in my chest,” Franklin said.

New research shows 42 percent of women under 55 do not feel chest pain during a heart attack. And hospitals often don’t diagnose those women properly until it’s too late.

“When women arrive to the hospital having a heart attack with symptoms different than chest pain, their care might not happen as immediate,” cardiologist Dr. Suzanne Steinbaum said.

Researchers say that’s why more than 14 percent of women are dying from heart attacks in the hospital compared to 10 percent of men.

Doctors say there are signs a woman can look out for besides chest pain.

“They might have other symptoms like jaw pain, back pain, shortness of breath, nausea, fatigue and simply sweating. All of these things could be a heart attack,” Steinbaum said.

Steinbaum says for any woman noticing those symptoms, getting help immediately could be critical.

“The quicker you can get to treatment the quicker we can save heart muscle and prevent you from dying,” she said.

Franklin had a stent put in to clear an artery.

“I am definitely lucky to be alive today,” Franklin said.

Now at 60 she says she feels much better.

The study stresses that chest pain and discomfort are still the primary symptoms of heart attacks, whether a man or a woman. But researchers say don’t ignore other kinds of pain as well.

Doctors also say every woman starting at age 20 should have her cholesterol and blood pressure checked on a regular basis to assess her heart attack risk.

Patients often ask what’s more important: exercise or losing weight?

As winter rolls through the Northern Hemisphere, maintaining fitness seems a timely and relevant topic.

Heck, maintaining or gaining fitness should always be a relevant matter!

A recently published study seems worth a comment on Cycling Wednesday.

In this math-heavy publication in the journal, Circulation, researchers from South Carolina, shed light on the importance of maintaining, gaining or losing fitness over time.

The Aerobics Center Longitudinal Study followed 14,435 men over 11 years. Researchers looked at how changes in fitness (measured by 2 treadmill exercise tests) and body weight (measured by BMI–Body Mass Index) related to death rates. Math people would say they focused on the delta—the change over time. (I added that sentence because I have fond memories of Calculus, and of course, I like to sound smart. < Insert > Grin.)

Here is a sifting down of the five major findings: (Again, good summaries–by professionals–can be found at CardioBrief and TheHeart.org.)

Men who maintained fitness reduced their death rate by 30%
Men who gained fitness reduced their death rate by 39%
Conversely, men who lost fitness doubled their risk of dying from heart disease.
For every 1 MET improvement in fitness (about 20 seconds/mile pace), there was a 15% reduction in death rate.
After adjusting for other causes, including changes in fitness, BMI by itself did not influence the risk of death.
This study reinforces my view that fitness remains central to health. The main contribution of this large and robust study stems from the novel finding that improving and maintaining fitness over time lowers mortality risk, while losing fitness worsens risk.

What’s up with the BMI data?

How could body weight not be significant?

The lack of effect of changes in weight are confusing. Some have interpreted the study as consoling to those who don’t lose weight but gain fitness. I have even read some headlines that suggest reducing fatness doesn’t reduce heart disease risk. That’s not what I think the study shows.

Rather, it showed that when BMI was looked at alone, excluding fitness, there wasn’t a significant increase in risk. That’s because most who gain fitness lose weight.

Also important is that this study looked at a specific and narrow population: men that were either normal weight or only slightly overweight (the average BMI was 26—thin by KY standards). Those individuals at normal body weight may not lose much weight when they begin an exercise program. Muscle mass increases can counter fat loss.

As pointed out by the researchers, it’s likely that losing weight would lower risk far more for those who are truly obese. My gut tells me that going from a BMI of 35 to 30 (14% less) would reduce risk more than going from 26 to 22.5. But what’s cool about the study findings is that normal weight people can markedly decrease heart disease risk by holding onto or gaining fitness.

So yes, I see this study as good news for the seemingly healthy patient who asks, “Doc, what else can I do to reduce my risk of dying?” Get fit, or fitter!

I also see it as a warning to competitive athletes to maintain fitness during the non-racing season. (Though not a coach, the thought of doing a different exercise in the off-season poofs into my mind here.)

The bottom line: fitness remains an incredibly powerful predictor of health. And fitness can be measured easily, without expensive scans or exposure to radiation.

For simple minds and minimalists, such news is reassuring.

JMM