In the last few years the endurance community has been beseeched by untimely deaths (Ryan Shay, Steve Larsen) and most recently unexpected retirements (Torbjorn Sindalle). It makes us all, pro and amateur endurance athletes alike, pause for a minute and think is this life I have chosen the right one?
Well, I am here to tell you as a cardiologist and an endurance athlete I don’t think about it too long because the benefits outnumber any risks. Ryan Shay, Steven Larsen and Torbjorn Sindalle are the unfortunate exceptions to a very simple rule. Exercise, don’t smoke, eat a healthy diet, maintain an appropriate body weight (i.e. don’t be fat) and your body will reward you by allowing you to live a healthier, disease free, happier, and more energetic life.
Unfortunately, for most of us, we tend to focus on the exceptions to the rule. I see this everyday in my practice. I can be counseling a 30 year old on the horrors of smoking and she tells me about her grandmother who smoked 3 packs a day, lived to be 98, and died peacefully in her sleep. She says this so emphatically like some how this negates the millions of people who smoke and die of lung cancer, heart disease, and emphysema every year.
Being physically fit outweighs the risks of not being physically fit any day of the week. However, in saying that, it is definitely not good for your mental well being to be out there on a 50 mile bike ride and wondering if you drew the short straw at birth (genetically speaking) and are destined to drop dead at mile 49.
In a hopeful attempt to ease your mind, let’s talk a little about these three athletes and what you can do to reduce your risk of meeting the same fate.
Ryan Shay likely died of a ventricular arrhythmia (abnormal and generally lethal heart rhythm) caused by an area of scar tissue in the heart. This area of scar tissue was likely caused by a past infection that had affected the heart muscle.
Every time we get a cold, we pretty much take it for granted that it will run its course and then we will get back to normal. We typically think of a cold as affecting our eyes, ears, nose and throat but rarely these viruses can also affect our heart. In the worse case scenario, someone presents with heart failure or in other words the virus (or the body’s immune system response) has attacked the heart leaving it weak, dilated and very susceptible to lethal arrhythmias. I probably see this happen about a few times a year.
A more insidious pathway however, is probably what happened in Ryan Shay’s case. At some point in the past he had an infection from which he recovered but unknowingly caused some permanent damage to his heart. This event set the stage for the presumably lethal arrhythmia from which he eventually died.
Is this to say that if he wasn’t a professional athlete who was constantly pushing his body to the max that he would not have died? If he had been an overweight, sedentary guy whose idea of exercise was trying to bend all the way over to tie his shoes would he have suffered a different fate? Although, we can never know for sure, I think the answer is probably no.
Steve Larsen’s death is still somewhat of a mystery to me. The official autopsy says he didn’t die of a heart attack or a blood clot and according to reports he was having some type of respiratory difficulty in the weeks leading up to his death. Mostly likely, just like Ryan Shay, he died of a ventricular arrhythmia. What precipitated the arrhythmia we may never know.
Torbjorn Sindalle is a very different story. He was born with a bicuspid aortic valve (which he had known about for years) and in the midst of a stellar career with the advice of his doctors he decided to retire.
For those of you who need a refresher course in biology, your aortic valve in the heart valve that sits between your left ventricle and aorta. Blood, fresh with oxygen, comes from your lungs and goes into the left atrium through the mitral valve and into the left ventricle. When your heart contracts the pressure (in the left ventricle) causes the aortic valve to open allowing blood to flow into the aorta and out to your body (via arteries).
A normal aortic valve has three cusps (of leaflets) and a bicuspid valve has two. A bicuspid aortic valve is the most common congenital (means you are born with it) cardiac abnormality that we see and is probably present in 1-2% of the population.
Nature works in very specific ways and unfortunately does not leave very much room for error. When I think of the natural history of a bicuspid aortic valve, it reminds me of Europe. I think of the times that I have traveled around Europe looking at great masterpieces and see the effects that nature or in some cases human nature can have on them. In particular, there is a very famous fountain in Rome that at first glance appears to be very well preserved but when you go around to one side you see this huge indentation in the marble at the base of the fountain. I remember when I first saw this I was perplexed but after standing there for a little while and seeing that that indentation was the spot where people would come and kneel to say a prayer or ask for a wish, it then became clear. Millions of people kneeling the same spot day after day, year after year, decade after decade, had worn the marble down to create a very impressive indentation in a pretty resilient substance. It is pretty hard to fathom it when you are the one kneeling there but nonetheless it is that simple action done a million times over that led to the problem.
A bicuspid valve at birth seems on the surface to work just as well as a normal (tricuspid) valve. But over time, that very slight difference in the way the valve opens and closes, causes it to slowly wear down over time. In Torbjorn’s case his bicuspid valve has led to a problem with aortic regurgitation (leakiness). Normally what happens after the left ventricle contracts and blood goes through the aortic valve into the aorta is the pressure decreases in the left ventricle and causes the aortic valve to slam shut preventing blood from leaking back into the left ventricle. In Torbjorn’s case, after the left ventricle contracts and the aortic valve closes it doesn’t form a tight seal and blood leaks back. Over time this leads to dilation (enlargement) of the left ventricle and aorta (which causes the valve to leak even more). Untreated this can increase the risk of heart failure (and sudden death due to a ventricular arrhythmia), or aortic dissection (actual ripping of the aorta) both of which can be quite fatal.
Does that mean that someone who has a bicuspid aorta valve should not exercise? Absolutely not!! Torbjorn’s decision to retire from the world of professional endurance sports is not saying that he is going to become a couch potato, sit around and do nothing. It means that he is no longer going to subject his body to extreme physiological stress that might put him at increased risk of dissecting his already dilated aorta.
So what does this all mean to the average Joe (or Josephine) endurance athlete? I hate to say it but this isn’t the last time that someone well-known and respected pro or amateur athlete will die suddenly. It will continue to happen, just like people will continue to die in car crashes and planes will suddenly fall from the sky. However, just like we can do things to reduce the chances of this happening (like wear seatbelts, and have planes get regular scheduled maintenance), we can also do things to make sure that we lessen our chances of dropping dead suddenly on a training ride or at a race.
Here are my suggestions:
Know your family history- Do you have any family members who were seemingly healthy and then died at an early age? Are all your relatives dying of heart attacks in their forties and fifties? These are red flags and should be taken seriously.
Do you have high blood pressure, high cholesterol or diabetes in your family? If you do then you are at increased risk and should be tested.
Get screened. Simple tests like a good physical exam, EKG, echocardiogram, stress test, or cardiac CT can identify a lot of these congenital abnormalities before it is too late.
Don’t assume because you are athletic that you are healthy. When was that last time you had your cholesterol, blood sugars or blood pressure checked?
Be a smart consumer. Just because it isn’t banned by the WADA doesn’t mean it is completely safe. There are a multitude of products (supplements, energy drinks/shots etc…) out there that purported to increase your performance but at what price? Avoid them. Their claims are anecdotal (not scientifically tested) and their safety questionable.
Stay well hydrated, well rested, and properly fueled. When disaster strikes it generally happens when you are at your weakest. If you are exhausted, dehydrated, depleted of calories and electrolytes you are just upping the ante that something bad will happen.
Don’t fear the doctor. Your doctor should be your friend. Let him or her know your fears and concerns so together you both can come up with a plan to help keep you exercising until a ripe old age
Be Happy. No one lives forever (as far as I know). If we obsess about all the things that could kill us, most of us would never make it out of the door each day. Relax, follow the above steps and you should be just fine.
-Dr. Sal (The Raw Cardiologist)