Health Info

Cardiac Safety for Runners
Have a heart- safe marathon in 2020!

Dr. Akshay Mehta

One of the great benefits of a marathon is that it has stimulated an increase in physical activity in the population.

However, although physical exercise promotes health and prevents heart disease and heart attacks, we also sometimes see a paradox: young, healthy looking people having heart attacks or dying suddenly during training or during marathon running.

The commonest cause of running-related sudden cardiac death is underlying undiagnosed atherosclerotic coronary heart disease or inherited conditions of the heart (like a condition called 'hypertrophic cardiomyopathy').

To combat this problem, we need a two- pronged attack:

1. Prevention 2. Prompt treatment

1. Check for factors which increase your risk of having a heart attack such as:

  • History of heart disease, heart attack, sudden death, angioplasty or bypass surgery inyourparents, brothers or sisters especially at young age (<55 years in father or brother and <65 years in mother or sister)
  • Any of the following in yourself:
  • Heart attack, angioplasty or bypass surgery in the past
  • Hypertension, diabetes, cholesterol (lipid) abnormalities
  • Smoking habit
  • Sedentary lifestyle (less than 3 days per week of moderate physical activity)
  • Unhealthy eating habits (high fat and sugar intake)
  • Psycho social stress, poor sleep
  • Obesity (especially waist girth more than hip circumference)
2. For people with one or more of above risk factors and for people above 35 even without the above risk factors, seek a medical check-upwhich shouldconsist of:

  • Clinical examination by a physician or cardiologist
  • ECG
  • Blood tests: CBC, Fasting Blood Sugar, HbA1C, Lipid profile, hs CRP, hs Trop I, Homocysteine, Renal Profile, Liver Function Tests
  • Treadmill stress test

The above are advisable not only before joining the vigorous exercise program like marathon training, but also every year in people indulging in strenuous exercise like running.

For people starting a running program for the first time (first timers), the following additional tests may also be considered after consultation with your cardiologist:

  • 2 D Echo
  • CT scan for CORONARY ARTERY CALCIUM SCORE (risk increases with a score of 100 or more)
  • For people at high risk as defined by the examination and test results, a CT coronary angiography also may be advisable after discussion with your doctor.

3. Control of hypertension, diabetes and abnormal cholesterolby life style changes or medications if required, in addition to life style changes.

4. Statins for people at high risk as judged by personal physician after discussion about risk versus benefits.

5. Pre-race aspirin (detailed later, below)

6. Exercise routine:
Start slow -when starting afresh. For initial weeks exercise at very low intensity (at 50 to 70% of your maximum predicted heart rate, which is roughly calculated by 220 minus your age) and pick up in intensity and duration after a few weeks. Same precautions should be observed when RE-STARTING after a break of more than a week.

7. Take a minimum of four months and ideally six to prepare for the marathon and get your body used to the extra stress being placed on it.

8. Train three to five times per week and build your weekly mileage over time, with runs of varying intensity in terms of distance and speed.

9. Warm up and cool downat every session, each for about 5 to 10 minutes.

10. BE REGULAR.Regularity and frequency of physical activity is more important than intensity. IF THERE IS A GAP OF MORE THAN EVEN A FEW WEEKS, START ALL OVER AGAIN WITH LOW INTENSITY EXERCISE AS ABOVE.

11. Listen to your body:STOP exercising and go to your doctor or hospital if you have any of the following feelings at any time before, during or after exercise:

  • tightness or heaviness in chest,
  • unusual breathlessness,
  • fainting or dizziness,
  • nausea or vomiting sensation,
  • discomfort or pain in the chest, back, arm, jaw or throat or unusual gas or indigestion.

These could be warning signsof an impending heart attack and need to be reported immediately.

12. Pay attention to warning signals which may sometimes occur in some people few hours or days before a heart attack or cardiac arrest- like chest discomfort, unusual breathlessness, flu like weakness or fatigue.

13. Ensure proper rest or sleep for 7 to 8 hours daily. If your sleep has been less the previous day or night, or if you have not rested well the previous day, skip the next exercise session or make it very light.

14. Be well hydrated-drink enough water and fluids after a workout.

15. Eat healthy- which means fruits, vegetables, sprouts, nuts, pulses, legumes, low fat milk and whole grains. Avoid fried, processed, fast food. Avoid heavy meals and alcohol.

16. Avoid smoking or consuming tobacco in any form, totally.

In summary if you have been medically 'screened' properly, if you make a gradual entry into an exercise program, building up your stamina and endurance slowly and safely, noting any unusual symptoms at any time, are leading a healthy lifestyle with diet, regular exercise and sufficient sleep, using protective medications if advised and enough fluids, you can keep your heart safe for a marathon.

The key, particularly for inexperienced runners, is to not do too much too soon, to follow a good training plan, and to "listen to your body".

First, recognize the difference between a heart attack and cardiac arrest.

The chief symptom of a heart attack is chest pain or discomfort anywhere from the navel to the jaws-front or back.

The treatment is to immediately shift to the nearest hospital.

On the way and if available, let the patient chew a tablet of soluble aspirin (like Aspisol or Disprin)

A heart attack (or "acute myocardial infarction") occurs when blood supply to a portion of heart muscle stops, as a coronary artery gets blocked, and the part of the heart muscle that is fed by that artery is damaged. The interruption in blood supply is usually due to a blood clot occluding the artery which has already been narrowed by fatty deposits that have grown over months or years. The resulting damage to a portion of heart muscle takes few hours to complete.

Its treatment is opening of the blocked artery by injecting a clot bluster into a vein, or (better) by emergency angiography and balloon angioplasty with stent implantation in the blocked artery.

Hence its main treatment is in the hospital and shifting a 'conscious' patient with chest pain to the hospital is the first priority.

On the other hand,

The chief symptom of cardiac arrest is sudden collapse with loss of consciousness, pulse and breathing.

The electrical impulse that causes heart to beat rhythmically, suddenly either just completely stops and becomes electrically silent, or it becomes so fast and erratic that your heart muscle just quivers - literally quivers - and pumping of blood and supply to the entire body including to the brain stops.

This is like switching off an electric current and can result in death or permanent brain damage within minutes if not attended to immediately.

Hence its treatment has to start on the spot or the place where cardiac arrest occurs, in seconds.

Shifting to the hospital IS NOT THE FIRST PRIORITY.

Treatment consists of giving an electric shock to restore heart's rhythm to normal with a DEFIBRILLATOR. A type of defibrillator that can be used by a lay person by listening to voice prompts is an Automated External Defibrillator (AED) which are usually available at marathon stations. Cardiac ambulances also are equipped with defibrillators.

However, till the AED or the cardiac ambulance arrives on the scene, chest compression CPR should be started by whosoever is near the victim. There is no need of mouth to mouth ventilation.

So,if you see a co-runner collapse who doesn't respond to your calling or shaking him or her and has abnormal or no breathing as gauged by chest and abdominal wall movements, recognize this as a cardiac arrest and:

1. Call for help-for either an AED or an ambulance having one. PLEASE STORE MARATHON CENTRAL STATION PHONE NOS IN YOUR PHONE SO THAT IN CASE YOU SEE SOMEONE COLLAPSE YOU CAN ALL THIS NUMBER TO INITIATE A CPR RESPONSE. 2. Initiate CPR (Chest compressions) - 100 per minute, 2 inches deep, with hands placed on lower end of breast bone (picture) 3. Electric shock once AED arrives.
There are useful videos showing how this can be done by almost anybody. (Learn Hands-Only CPR from the American Red Cross).

It has been seen that the chances of survival increase from less than 10% when people don't know the CPR steps to more than 50% when the majority of people know all the steps of CPR and perform them.

Photo credit to: The University of Arizona Sarver Heart Center
Is there a relation between heart attack and cardiac arrest?

Most heart attacks do not cause cardiac arrest, but some (up to 30 % of) heart attacks do lead to a cardiac arrest that most commonly occurs in the first hour after onset of chest pain.

Conversely, most cardiac arrests (up to 70%) are caused by a heart attack or severe coronary artery disease (blockages) or enlarged hearts with heart (pump) failure. Rarely (especially in young athletes), inherent structural or electrical abnormalities of the heart may be the cause.

More on 'Pre-Race Aspirin':

Half a tablet of soluble aspirin (Disprin or Aspisol 325 mg) may be advisable a day before and in the morning of the run (training or marathon itself), especially in people with risk factors mentioned above or in people with high calcium scores above 100 on CT scan. But only after a full discussion of risks and benefits and with approval by your personal physician or cardiologist.

Although there hasn't been a scientific study to test or prove this, the concept of pre-race aspirin seems logical if one considers the following:

  • Cardiac arrests occur in roughly 1 in 50 000 runners, mainly in males above 35.
  • Atherosclerotic coronary artery disease is the most common underlying cause of heart attacks and cardiac arrest. Studies in asymptomatic middle-aged male runners have demonstrated a high, iftransient, risk for atherothrombosis during marathons whichpromotes acute coronarythrombosis during or after a marathon.
  • Aspirin, in general is known to reduce heart attacks (acute myocardial infarctions) inhealthy males by 44%, as per the Physicians Health Study.
  • Firefighters are at increased risk for sudden cardiac death during emergency duties inpart related to increased clotting tendency during strenuous duty.
  • Attenuation of pro-clotting effects by aspirin as seen in studies on firefighters would apply as well to runners.
  • Use of pre-race low-dose aspirin seems prudent to prevent race-related heart attack and sudden cardiacdeath. However, the benefit of taking aspirin has to be weighed against the smallchances of allergic reaction, peptic ulcer aggravation or stomach bleeding due to aspirin. Also, it should be avoided if your BP is uncontrolled and above 140/90 mm Hg.
Hence, since 2015 the advisory from IMMDA (International Marathon Medical Directors Association) states that:

"Long-distance runners, especially men over the age of 40, are advised in the absence of specific contraindications to take pre-race aspirin if approved by their personal physician after discussion of its risks and benefits."

Discuss with your doctor about it.

So, let us all endeavor to make the marathon and its training as safe as possible by prevention as well as by prompt recognition and treatment of cardiac catastrophes should they occur.

Have a heart safe marathon!

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