Tuesday, August 9, 2011

Cardiac Arrest During Triathlons

With all the buzz about the two tragic deaths at the NYC Triathlon this weekend, there have been a lot of emails going around our triathlon club. Working as a Nurse Practitioner in Cardiology, this is obviously my area of specialty. That being said, the following blog is my insight (based on medical expertise), not meant to diagnose anyone. If you have cardiac symptoms, stop sucking it up and SEE YOUR DOCTOR.

This year there have been several tri deaths/cardiac arrests.

In May, a man competing in a tri in Florida collapsed. A nurse who was competing in the race stopped, resuscitated him using a defibrillator from nearby police officers, and finished the race. (She saved his life, by the way). Read the story here.

Also in May, this time in Colorado, a father and daughter were running the marathon in Fort Collins together. Her goal was to qualify for Boston. She came upon a man in cardiac arrest and stopped to help. She then realized it was her father. Thankfully, he did well. Read about it here.

So while the highest number of deaths are during the swim (less opportunity to identify/help people in distress), endurance sports in general are dangerous to people with diagnosed and undiagnosed cardiac illness.

The good news? (Yes- there is good news). Regular exercise significantly reduces the risk of sudden cardiac death.

So now for my cardiac insight:
There are three different areas of cardiac issues (and I use this same analogy with my patients):

Plumbing Problems: Coronary artery disease (blocked arteries). This is what causes your traditional "heart attack".

Modifiable risk factors for CAD (things you can change- most of these aren't an issue for triathletes):
-Tobacco smoke
-High cholesterol
-High blood pressure
-Physical inactivity

Non-modifiable Risk Factors:
-Increasing age (63% of people with heart disease are 65 or older)
-Male gender

Warning Signs of CAD (from American Heart Association):
- Chest discomfort (this may be pressure, fullness, or pain)
- Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.
- Shortness of breath with or without chest discomfort.
- Other signs may include breaking out in a cold sweat, nausea or lightheadedness.
Not everyone has chest pain with a heart attack! I can't tell you how many people I see with vague symptoms like fatigue, weakness, nausea/vomiting, and NO chest pain!

"But I'm a triathlete who trains 6-7 days a week and I don't have any problems". By definition, triathlon is "painful". Sometimes vague symptoms of cardiac problems can be masked by all the wonderful things we feel during training/racing. (Who hasn't felt nauseated, short of breath, fatigued????) In an article outlining 19 years of the Marine Corps Marathon, there were 4 deaths. 2/4 had run marathons before. On autopsy, 3/4 had significant coronary artery disease but no previous symptoms or diagnosis.

"Electrical" Problems
These can be abnormalities in the way the electricity travels through the heart, or arrhythmias (abnormal heart rhythms- either too fast or too slow).

Too Fast- Some of these rhythms can be non-threatening (read about my own experience with Supraventricular Tachycardia here), while others can be life-threatening.

Too Slow- Yes, most endurance athletes have slow heart rates, but some abnormal heart rhythms (such as heart blocks where not every electrical signal goes through the heart)can be dangerous. I have a friend in her 30s with such a problem. She is on her second pacemaker and runs marathons (much faster than I do!).

Causes of Abnormal Heart Rhythms:
-Congenital abnormalities
-Underlying cardiac problems
One of the conditions we see most often in otherwise healthy people is Cardiomyopathy. This is an enlarged, weakened heart. Heart attacks can cause this, but also viruses, pregnancy, alcohol, and sometimes idiopathic or unknown causes. I have taken care of two alcoholics recently who were diagnosed with severely reduced heart function (both young), and previously unaware. This is the condition which is most often implicated in the deaths of younger athletes who suffer sudden cardiac death.

-Illicit drugs
-Over-the-counter and prescription medications

Risks of Serious Arrhythmias:
-Sudden cardiac death (these patients may not have warning or symptoms prior to the cardiac arrest)

Symptoms of Arrhythmias (From American Heart):
- Arrhythmias can produce a broad range of symptoms, from barely perceptible to cardiovascular collapse and death.

- A single premature beat may be felt as a "palpitation" or "skipped beat."
Premature beats that occur often or in rapid succession may cause a greater awareness of heart palpitations or a "fluttering" sensation in the chest or neck.
- When arrhythmias last long enough to affect how well the heart works, more serious symptoms may develop:

-Fainting (syncope) or near-fainting spells
-Rapid heartbeat or pounding
-Shortness of breath
-Chest pain
-In extreme cases, collapse and sudden cardiac arrest

Structural Abnormalities
Valvular (“heart murmur”)

Why are there more issues on the swim?
-Cold water (This may induce some abnormal heart rhythms. Treatment for one of the rapid rhythms in the Emergency Department used to be sticking the patient's headin a bucket of cold water).
-Sudden surge of adrenaline (This can increase heart rate and blood pressure, increasing the risk of heart attack or arrhythmia).
-Inexperience/ Inability to stop or ask for help

What should you do as an endurance athlete?
Have an annual physical.
It is reasonable to ask for an annual ECG (electrocardiogram). This will not necessarily show CAD, but may show an enlarged heart or other problems).

If you have symptoms, see your physician. The phrase "better safe than sorry" is definitely appropriate here. What can they do?
- A cardiac stress test to look for CAD, blood pressure changes with exercise, abnormal heart rhythms with exercise
- An echocardiogram (ultrasound of the heart) to look at the heart structure and function
- An event recorder or home monitor to capture abnormal heart rhythms

Again- none of this is meant to replace the advice of your physician, but hopefully it sheds some insight.

DOES EVERY TRIATHLETE NEED A STRESS TEST? NOT NECESSARILY!!!!! See your physician, assess your risk factors, and go from there.

The #1 thing I think all of us can do as athletes? LEARN CPR. CPR can save lives (as indicated by those two stories at the beginning of this post). It may not be another athlete you save, but a friend, family member, or complete stranger. If I haven't bored you completely, this is a very cool video about a patient I took care of whose life was saved by her running buddy. The neatest part about this? We were at a swim meet this summer and Tommy was timing two lanes from Shari. He recognized her and said hello. There isn't much in life more rewarding than seeing someone who was so sick doing so well!


  1. Great post Kier, very insightful. You know, after—and I am embarrassed to admit this—five years without a physical, I finally decided as a father of five children, I needed to suck it up and go and get one despite feeling like I am in exceptional shape. I got a clean bill of health and blood work that would make Dracula blush, but I did have a friend with a young family have a stress test recently to find out that he has a minor cardiac (if there is such a thing as a "minor" ) cardiac issue.

    Prevention is the key, and not imagining we are still eighteen, especially for us men.

  2. Thanks for this Kiersten, I learned a lot!

  3. Kiersten, thank you so much for this blog post. Great information. Jeff thanks for directing me here.

  4. Sadly, my physician knows very little about athletes, including tria-what-thlon. I felt that my last physical was completely useless, hence the reason I don't get them often. Good advice to request the ECG.