By PCG Elite Coach David Ertl
I was invited to review the book The Haywire Heart,
written by Dr. John Mandrola, Lennard Zinn and Chris Case,
recently published by VeloPress. This book primarily addresses electrical
problems in athletes’ hearts but also touches on plumbing issues (clogged
arteries, or atherosclerosis).
The book’s cornerstone is the observation that lifelong
endurance athletes seem to be developing heart arrhythmias, including the case
of one of the authors, VeloNews tech editor Zinn, who was the focus of the
cover story on the topic in VeloNews in 2015 that led to the writing of the
book. The book investigates the question of whether continued exercise for
sport, above and beyond what is good for health, is beneficial, or can it reach
a point where it becomes detrimental?
Who should read this book?
• Anyone who does intense or long endurance training,
especially over many years
• Anyone who exercises and has a history or any sort of
arrhythmia
As I started reading this book I had questions in mind
around two of its central theses.
First, is the observation that more arrhythmias are
appearing in lifelong athletes real, or is it simply that there are now more
older endurance athletes? After all, more arrhythmias are observed in
non-athletes as they age, as well. The 60- and 70-year-old athletes represent
the first generation of people who have been lifelong athletes, and this may
just be part of normal aging.
The second question has to do with how much exercise is too
much. What is “extreme endurance training,” and am I doing it? Am I actually
hurting my heart by being a lifelong recreational, yet competitive, cyclist.
Should I back off?
Almost Like a Medical Journal
The book went into great detail explaining the various heart
ailments that may show up in endurance athletes and reads like a medical
journal at times. To greatly summarize, arrhythmias are any abnormal impulse in
the heart, such as atrial flutters (very fast heart rate), atrial and
ventricular arrhythmias (fast and irregular heartbeats), and tachycardia (fast
heart rate).
These conditions may be caused by extreme endurance
exercise, as such activity can lead to stretching, inflammation, scarring and
enlargement of the heart tissue, which are all factors that can lead to
arrhythmias. The authors make a fairly convincing argument that extreme
endurance exercise causes these conditions that can then set the stage for arrhythmias.
Another factor that may lead to arrhythmias is the low heart
rate experienced by many endurance athletes, which may lead to premature heart
beats. Endurance athletes can experience a wide range of heart rates, from very
high during exercise to very low at rest. The authors present information that
indicates that endurance athletes appear to have a greater occurrence of
arrhythmias than sedentary counterparts, thus answering my first question.
There are treatments for arrhythmias, which include drugs
and surgical (ablation) procedures, where areas of the heart tissue are
actually burned and destroyed. These treatments all contain side effects and
risks and may not be completely effective in controlling the arrhythmias.
The book also touches on atherosclerosis and heart attacks.
This was of particular interest to me as I have experienced a clogged coronary
artery despite my fit lifestyle. As the authors point out, while “exercise is
protective, it isn’t a panacea” and it doesn’t make athletes immune from
atherosclerosis.
The second half of the book gets into symptoms of heart
problems you can look for yourself to determine if and when you should seek
medical help. Some symptoms are less serious than others, such as
palpitations. Others are much more serious, such as racing heart, chest pain
and difficulty breathing.
The book then discusses the sort of tests to expect if you
do see a doctor, and the information you should take with you. It’s pointed out
that athletes have a high pain threshold and tend to downplay pain and
discomfort and may try to brush aside and ignore symptoms.
Being Fit Not the Same as Being
Healthy
It’s important to realize that being fit is not necessarily
the same as being healthy. (There are countless examples of extremely fit,
well-known athletes who have died of heart attacks or other heart ailments they
never knew they had; a commonality seemed to be the assumption on their part of
good health and thus the lack of regular medical checkups.) And the book
presents some evidence that long-term endurance training may not protect
against atherosclerosis.
Answers to my second question – how much exercise is too
much – are less clear, and the answers may not be known at this time.
Throughout the book the authors use terms such as “elite
athletes,” “extremely intense” and “competitive.” They utilize several case
studies highlighting very elite athletes who were on the U.S. national cycling
team, U.S. Ski Team, competed in world running championships and masters
athletic championships.
The non-elite athlete case studies involved athletes who
were very driven, in some cases obsessed, exercisers who participated in
multiple marathons or ultra-marathons and typically had type-A personalities
both in sport and in other aspects of their lives. These case studies appear to
be extreme examples.
For instance, one recreational athlete was an independent
sales representative who worked and played hard, often on the same day. He
admits he was burning the candle at both ends and that he was chronically
overtrained. He would do a ski marathon on Saturday, drive to another on
Sunday, and do some work in between. He experienced ventricular tachycardia
followed by cardiac arrest at age 50. He was fortunate to survive. He admits he
did it to himself through by letting his personality drive him to extremes in
every aspect of his life.
I don’t put in nearly the quantity of training that the
athletes in these case studies did, although I often do intense training along
with long slower distance training, and have done so for 44 years. I was
somewhat comforted by the statement: “These are a highly selected groups of
athletes.... They represent a tiny fraction of elite athletes. The vast
majority of endurance athletes do not develop severe ventricular arrhythmia.”
The book asks the question “So why do most endurance
athletes not have arrhythmia? It is not known who will be affected, but
overdosing on exercise appears to increase risk of arrhythmias.”
What To Do With This Information?
What we do with this information appears to be an open
question that each of us must answer for ourselves. And most likely it is a
very individual situation where some of us may be more immune and others more
susceptible. What is too much for one person may be tolerable to another. We
may not know until it is too late.
As I read this book I kept asking myself, “Does this
describe me?” or “Could this happen to me?” The odds are in my favor that it
won’t, but I thought the same about cardiovascular disease – and it did happen
to me.
On the other hand, I recently read another book, also
published by VeloPress, titled “Fast After 50,” by Joe Friel, which advocates
for continuing to do intense training into old age to maintain fitness. Each of
us must balance the risks and benefits and make our own decisions.
As a coach, I have worked with two cyclists who have had
heart rhythm issues, including one in his 30s who ended up having an ablation
procedure done, so I understand it does happen. The Haywire Heart does give us
reason to pause and consider our circumstances.
For example, another thing the book considers is, if you are
a middle-aged or older athlete who took up sport later in life, you may carry
along years of accumulation of poor fitness and perhaps poor health (e.g.
atherosclerosis), which may be exacerbated when taking up an endurance sport.
Suggestions From the Authors
The authors provide some suggestions to help avoid or detect
problems.
One is to “rest as hard as you train.” Fatigue seems to be a
central theme among athletes developing arrhythmias. Avoiding overtraining may
be one key to staying healthy, as well as managing stress in all aspects of our
lives while training.
Another suggestion is to wear a heart rate monitor at all
times while training. This can help detect problems we may not be aware of, and
can serve as useful information to a doctor should an episode occur.
So How Will This Book Affect Me?
I expect I will continue training and racing. I will likely
wear my heart rate monitor more often now, and I will certainly be more
cognizant of any irregular sensations related to heart rate. I don’t believe
the authors are trying to get us all to stop our intense or competitive
endurance training regimes (although sometimes it sounds like it). Instead, it
seems, they do want to raise awareness of the issues, recognize problems when
they occur, and provide some information about behaviors that may lead to
problems down the road.