Sudden Cardiac Death in Runners

Sudden cardiac death due to atherosclerosis is a tragedy that can strike any runner over the age of 35.  Because we stress our bodies, many runners are at a higher risk of dying from sudden cardiac death than many of our sedentary friends.  Why is that and what can we do to determine our risk and if lifestyle modifications or active treatment is necessary?

Did you know that you can leave your Cardiologist’s office after a normal stress test, hit the road and suffer a massive fatal heart attack?  It’s true.. so bear with me and read the rest of this post.

Steve was a very active 60 year old teacher.  He recently retired and set his mind on improving his marathon times and perhaps hit a few tris along the way.  I had run with Steve on a few races.  He never faded back, never had any issues during a run until his last week with us.

Heart disease can be difficult to identify in many.  Roughly (don’t hold me to firm numbers) 50% of massive, fatal heart attacks occur in people without what you might consider to be obvious risk factors. Your doctor might feel otherwise. Risks for cardiac disease are well known:

• poor dietary choices
• smoking
• hypertension
• chronic NSAID intake
• poor sleep habits
• your innate desire to perform better

can all increase your risk of developing cardiac issues. Just because you run 4 days a week doesn’t mean you can have two donuts and a latte on the way to work everyday.

In retrospect, many sudden cardiac deaths are preceded by very subtle symptoms that any athelete might brush off due to a training effect, a bad meal or a cold.  For that reason death might be the first major sign of severe atherosclerotic heart disease.

Very few of us would see a doctor with symptoms of heart burn that occurred with exercise.  But you should. Very few of us would consider seeing a doctor for nausea which routinely occurs on long runs. But you should.  The signs of impending issues can be very subtle.  The classic main stream presentation of crushing chest pain is not a common way for us to present with heart disease.

Late last fall Steve and I hit the local trails as a prelude to his final trail races for the season.  Our pace and goals were normal, and neither of us were more tired than we were on any of our previous runs.  He did become a little nauseous one day, but he blamed that on a work lunch before a late afternoon hill run.

Subtle clues that a cardiac event might be forthcoming:

• fatigue – you’re more tired and not performing as well
• nausea- many of us bonk, get side-stiches, etc on routine hard days.  But new symptoms or new onset nausea associated with effort should trigger at least a discussion with a a health care professional.
• Neck, chest, arm discomfort associated with training.

Many of us do not have a good understanding of how a heart attack actually occurs.  Yes, you know that cholesterol plaques build up in your arteries. You know that can lead to narrowing of the arterial supply to your heart.  But.. sudden cardiac death doesn’t occur because of slow plaque growth obliterating the artery over a long time frame.

Steve took off on his final and favorite trail run shortly after 9.  By 10 he was face down in the gravel.  The coroner said the cause of death was sudden cardiac death due to a massive heart attack.

The plaque that forms in your arteries isn’t firmly covered like an impenetrable brick wall.  The plaque is actually friable and capable of “rupturing”.  If cholesterol builds up enough within a plaque, the plaque can rupture.  When it ruptures the inside of the plaque is exposed.  We have little cells in our blood called platelets.  Those main job of those little platelets is to stop us from bleeding.  If they feel a ruptured blood vessel as they bounce through your arteries they will sense it because of the collagen and other tissues exposed through the cut area.  The platelets stop, stick to the vessel and form a clump as they stick to each other.  This gathering of platelets helps form a web to trap blood cells and eventually form a clot which stops the bleeding.

Well.. if those same platelets sense a ruptured plaque in your heart’s arteries they will see those very same collagen structures that cause the platelets to become sticky and form a clot.  Your narrow coronary artery now becomes completely occluded as a clot forms and the blood flow is cut off to the part of the heart served by that blood vessel. So sudden cardiac deaths in runners or atheletes is an acute on chronic condition.  There was an underlying abnormality– the build up of plaque in the artery — but it is the sudden occlusion of the vessel by a clot that lead to death.

Those subtle symptoms or clues I mentioned earlier occur because of the plaque build up and the diminished blood flow to the heart.  Those subtle symptoms are the hearts way of telling you to pay attention to me.

Steve will be sorely missed.  He was frequently the life of the party.  He was always the first to the bar, the first to the dessert table and the last to leave.

If this is not an uncommon problem, then what are the possible ways that you can determine what your risk is.  Do NOT assume that because you run often that you are not at risk.  That can be a potentially fatal mistake.  Too many of my runner friends think that because they run they can have that cheesecake for dessert… or add a bowl of their favoritre ice cream on top of a warm apple pie. Therein lies much of the problem with heart disease… we think we are fine because we are active, and because we have no obvious symptoms.  Nothing could be further from the truth.

Heart disease is primarily a disease of inflammation.  Our diet, stress levels, sleep and family life have a lot to do with the amount of inflammation our body is subject to.  Diets high in processed foods, carbs, pasta, and sugar are highly inflammatory.  Work or home stress raises our cortisol levels and triggers a cascade of events that can lead to cardiac injury.  Too few of us consider sleep as one of the best ways to minimize stress and enable our bodies to recover.

Identifying who is at risk IS possible, and medical intervention or lifestyle changes CAN stop or reverse the potentially deadly changes occurring in the walls of your arteries.

The scientific knowledge and technology to determine your risk for sudden cardiac deaths is available. Sometimes you do not even need expensive tests to determine your risk factors. Known risk factors include:

• Family history of cardiac issues
• stress
• lack of sleep
• age
• obesity
• Inflammatory diet- high in refined foods, less veggies (No, you can’t eat that cheesecake because you ran today)
• Hypertension
• Cholesterol ratios

You will read many posts online about the need for advanced lipid profiles, cardiac calcium scores via  Cat Scan, ultrasounds of your carotid arteries and so on.  Some of you may “need” these techniques to give you “hard data”.  But sometimes hard data isn’t necessary.  We know the effects of these risk factors.  Running or cycling doesn’t give you a free pass to sleep less, eat whatever you want, ignore your elevated blood pressure and so on.

If your Cardiologist feels thats further testing is warranted then so be it.  But this is a space where big data isn’t likely to have a bigger impact on your heart health over the very timely and sensible advice of eating well, sleeping well, minimizing stress and paying attention to any subtle clues your body may be sending your way.

For more information I strongly suggest you read Dr John Mandrola’s blog