Athlete's Heart Blog

Caution! The Six Warning Signs You Shouldn’t Ignore

February 24, 2018 By Larry Creswell, MD 12 Comments

Some readers here at the blog will remember that I once wrote a monthly column for Endurance Corner, a multisport coaching outfit. Many of the links to those articles are no longer active, as readers have pointed out. One of the most popular Endurance Corner articles was a 2010 article entitled “Caution! The Five Warning Signs You Shouldn’t Ignore.” I thought I’d update the article here at the blog, and include an additional, sixth warning sign that athletes should also be aware of.

Over the years, I’ve noticed that my athlete friends seem to be very “in touch” with their bodies. They can be hyper-vigilant about the first signs of “swimmer’s elbow” or plantar fasciitis or leg muscle strain. They’re also apt to be proactive about dealing with these problems. Maybe that’s just because it’s sometimes easy to self-diagnose a musculoskeletal problem and easy to self-prescribe rest, ice, or analgesics. Maybe over time, they’ve learned the lesson that early intervention can head off bigger problems later on. That’s an important lesson, too.

I’ve also noticed, though, that my athlete friends sometimes give short shrift to some of the warning signs of potentially more worrisome problems—problems that stem from the heart or cardiovascular system. In my experience, it seems that men are worse than women. Like I’ve mentioned in previous articles, young “healthy” men just don’t like to go to the doctor. It’s easy to think that we’re invincible and ignore serious warning signs until they simply can’t be ignored any longer. But just like plantar fasciitis, it’s always best to recognize and deal with any serious heart-related problem earlier rather than later.

Here’s my short list of six warning signs that you shouldn’t ignore. These are symptoms that you should discuss with your doctor. Get reassurance if there’s really no serious problem and get thoroughly evaluated if your doctor believes there may truly be something wrong.

Chest pain or discomfort. Once every few weeks I meet with a small group of third year medical students to talk about patient scenarios that involve chest surgery. One of the scenarios that we discuss deals with a young man with chest pain. I ask the medical students to come up with a list of the potential causes and I’m always amazed at how many answers are offered up. Sometimes they’re able to list 30 or more. That’s the way it is with chest pain—many, many potential causes. These include things like injuries to the chest, reflux disease of the stomach, inflammation of the joints between the ribs and breast bone, anxiety, and diseases of the esophagus, among others. The students are quick to remember the potentially life-threatening causes such as heart attack (acute myocardial infarction), collapse of one of the lungs (pneumothorax), tears (dissection) of the aorta, the large blood vessel that carries blood away from the heart, and pulmonary embolism, the condition where blood clots form and travel to the lungs. I suppose that any of these causes may be in play for an athlete with chest pain. But the particular scenario that’s most important for athletes is chest pain or discomfort that comes with exertion and is relieved by rest. This can be an indication of coronary artery disease (CAD) that is usually caused by plaque build-up in the coronary arteries that supply blood to the heart muscle itself. In its early stages, the pain can be very subtle, perhaps nothing more than a twinge. In its later stages, the pain can be crippling. The good news is that, working with your doctor, you can be evaluated to see if chest pain is due to CAD. A variety of treatments may be available depending upon your situation. Don’t ignore chest pain!
Unexplained shortness of breath. As athletes, we’re all short of breath at some point—some of us earlier than others. And as athletes, we usually become accustomed to the level of shortness of breath that is associated with a given workout or level of effort. What’s worrisome is when there is some change to that pattern—when shortness of breath is unexpectedly out of proportion to what you’d ordinarily expect. That’s when the alarm bells should go off inside your head. Just like chest pain, there are a myriad of causes of shortness of breath, ranging from pulmonary or bronchial infections, to asthma (potentially made worse with exercise), to blood clots in the lungs (pulmonary embolism). For athletes, the most worrisome sign might be shortness of breath that persists after exercise stops or shortness of breath that occurs at rest. Both are signs that a heart condition may be responsible. This is a warning sign that you should report to your doctor.
Loss of consciousness. Much of medical school involves learning a big vocabulary of new “medical” words. Our word for sudden, unexpected loss of consciousness is syncope. Patients will use a variety of terms like “blacking out,” “passing out,” “falling out,” or even just “lightheadedness” or “dizziness.” Again, there are many causes, such as dehydration, side effects of various medications, etc. For athletes, one common scenario is near-syncope or syncope at the end of a workout, when the exercise is stopped abruptly without a period of cooling down. Thankfully, that situation can be avoided just by remembering to have an appropriate cool-down after each workout. The most worrisome type of syncope occurs during exercise. This almost always indicates a serious underlying medical problem—and often related to the heart. All cases of syncope should be discussed with your doctor, but it’s particularly important (bordering on emergency) to be evaluated if you have syncope during exercise.
Unexplained fatigue. Like shortness of breath, all athletes are familiar with fatigue. Almost regardless of the sport, fatigue just comes with the territory. It’s important to remember that, besides exercise, there are many causes of fatigue, including depression, the side effects of various medications, and anemia, among others. It’s also true that fatigue can be a symptom of underlying heart disease. Athletes become accustomed to the degree of fatigue that is associated with any particular workout or load and they should be acutely aware when there is a change to this pattern. Whenever there is a sudden change in an athlete’s pattern of fatigue or when the fatigue persists for an excessively long time, it’s important to get evaluated. Find out what’s going on.
Palpitations. Of the first five of these warning signs, palpitations—the feeling of an abnormally strong, fast, or irregular heartbeat that just grabs your attention—is undoubtedly the most common among athletes. It’s an unusual problem in school-aged athletes, but is very common among middle-aged endurance athletes. In some reports, as many as 70% of adult athletes report this problem. The palpitations may occur during exercise or at rest. We could make a long list of specific arrhythmias (abnormal heartbeats) that explain palpitations in athletes. The most common problems are due to abnormal heartbeats or rhythms (like atrial fibrillation) that start in the upper chambers of the heart (atria). Most of these arrhythmias are benign and require no treatment. But if you’re bothered by frequent palpitations, it is best to find out exactly what’s causing them, because they’re sometimes a sign of underlying heart problems that do require treatment. Resist the urge to ignore this problem.
Unexplained decrease in performance. I didn’t include this warning sign in my original list back in 2010, but I’m adding it here because of what I’ve learned over these past few years. By decrease in performance, I’m talking about an unexplained decrease in pace, endurance, or perhaps other measures of performance. Needless to say, there could be many reasons for such a decrement, including (poor) nutrition or hydration, various illnesses or injuries, the distractions of life outside of sports, depression, or even, simply, aging. All of those potential causes deserve attention, of course. But I’ve also seen cases where an unexplained decrease in performance, in the absence of any of the other five warning signs above, was the only indication of a serious heart condition. In situations where a decrease in performance persists despite consideration of the more innocuous causes, evaluation by your doctor with a particular eye toward hidden heart problems may be in order.

I realize this is a short list. But by paying attention to just these six warning signs, athletes can uncover many of the potentially serious underlying heart-related conditions that could place them at risk. Do this for yourself and remind your athlete friends, too.

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Getting a Second Opinion

February 20, 2018 By Larry Creswell, MD Leave a Comment

There can be tremendous value in getting a second opinion. I’m certain about that. At times, though, the process of getting a second opinion can cause unnecessary angst for patients and doctors, alike. It shouldn’t. Here’s my take.

What do we mean by a second opinion?

We’re talking about an additional opinion from a doctor who has not already been a part of things–somebody who did not offer the first opinion. Perhaps that’s obvious. Ordinarily, the process of getting a second opinion involves:

Gathering information (eg, records, test results) that formed the basis for the first opinion for some new doctor to review.
An in-person visit with the second doctor for the purpose of an interview and physical examination.
A discussion with this doctor, where the second opinion is shared with the patient, highlighting the similarities and differences from the first opinion.

Most commonly, we’re talking about second opinions from medical specialists or subspecialists rather than primary care physicians (PCPs).

When is a second opinion helpful?

Here are some situations where second opinions can be helpful. For each situation, I’ve included an example of an athlete-related heart problem.

When the diagnosis is uncertain. Not everything in medicine is black and white. As they say, the practice of medicine is both an art and a science. Sometimes, even when all of the relevant information has been gathered, it’s still not possible to decide with certainty as to a diagnosis. In this situation, a second opinion may help to sort out the diagnosis by bringing additional experience as well as a fresh set of eyes and ears to the problem.

An example. The condition known as hypertrophic cardiomyopathy (HCM) can be a difficult diagnosis to establish. There are known genetic mutations associated with this condition, but only a small percentage of cases can be diagnosed that way. In many cases, the diagnosis depends on the findings from echocardiography, magnetic resonance imaging (MRI), clinical features, and family history. In some athletes, there can be particular difficulty in distinguishing between an athletic heart, simply the result of exercise, and HCM. It’s easy for this diagnosis to be uncertain. In this situation, a second opinion may help to gather consensus about the diagnosis or suggest additional diagnostic testing that might be helpful.

When the treatment carries high risk, is expensive, or is logistically difficult. The diagnosis is settled and the conventional treatment involves a fair bit of risk. Often, we’re talking about a surgical procedure. In this situation, a second opinion may bring clarity to the need for treatment and confirmation that the planned treatment is appropriate.

An example. The condition known as bicuspid aortic valve (BAV) can involve regurgitation (leaking) of the aortic valve as well as enlargement of the nearby aorta to form an aortic aneurysm. When this diagnosis is established in a non-emergency setting and the patient requires replacement of the aortic valve and the nearby aorta, there are often several related, but technically different, surgical options. There are different types of prosthetic heart valves and different types of substitutes to take the place of the aorta. In each of these variations, though, the operation carries a fair bit of risk, is expensive, and can be logistically difficult, especially if operation must be pursued some distance from home. Here, a second opinion can be helpful to be certain about the diagnosis and the need for operation; provide clarity about how soon an operation should be performed; provide additional discussion about the various surgical options, with the advantages and disadvantages of each; afford an opportunity to re-address the amount of risk that comes with operation; and offer thoughts about the expected recovery timeline and return to exercise.

When there are several treatment options to choose between. After a diagnosis is established, the usual next step is to settle on a treatment. For many conditions, however, there can be several treatment options. Ordinarily, doctors like to share these possibilities with a patient and then decide together which treatment is best. This choice might depend not only on the medical specifics, but also the patient’s social, work, family, financial, cultural, or religious situation. But sometimes, even after discussion, it may not be easy to choose the best treatment. In this situation, a second opinion can sometimes be helpful to explain, from another doctor’s perspective, the treatment possibilities along with the advantages or disadvantages of each option. This doctor might well include additional or different possibilities or share the opinion that some of the previously considered possibilities may not be appropriate.

An example. One common arrhythmia problem in athletes is atrial fibrillation, or “Afib.” This is a problem that can be nagging or persistent over months or even years. Once an athlete patient has had this diagnosis established, there are often many options regarding treatment: lifestyle changes like losing weight, stopping tobacco or alcohol use, or moderating extreme exercise; medicines like aspirin, anticoagulants, or anti-arrhythmics; and procedural treatments such as arrhythmia ablation or left atrial occlusion. Moreover, a patient will find that his primary care provider (PCP) and perhaps even his cardiologist may not actually perform such ablation or left atrial occlusion procedures. In this situation, a second opinion might help to review the various treatment possibilities from another doctor’s perspective, and get another take on the advantages and disadvantages of the various treatment possibilities.

When it’s mandatory. Because of various regulatory frameworks, it’s sometimes necessary to get a second opinion before a patient can receive a particular treatment. Regulations at the local hospital level, from insurance providers, or from the federal programs like Medicare and Medicaid may all come into play in this regard.

An example. For patients with severe, symptomatic narrowing of the aortic valve (aortic stenosis), we often recommend aortic valve replacement (AVR). In recent years, a new approach for AVR, trans-catheter aortic valve replacement (TAVR), has become available for select patients. To satisfy requirements of the FDA and the Medicare program, patients must get opinions from two heart surgeons before they qualify for the TAVR procedure. In this situation, the second opinion is essentially mandatory.

When is a second opinion not helpful?

In an emergency situation. Second opinions are usually not logistically possible in an emergency situation. Here, patients must usually rely on the doctors that are tending to their emergency condition, even in the situations I’ve outlined above.
When the patient is already in the hospital. Once admitted to the hospital under the care of one or more doctors, it can be difficult to pursue a second opinion, at least in the common sense. If the condition or situation is not an emergency, sometimes it’s possible for partners of specialists to add their opinion, less formally, about a particular issue.
When two or more previous opinions are already similar. There is a diminishing return with multiple second opinions. When there is already a chorus of similar opinions, it’s likely the next opinion will also be similar. In general, it’s probably not wise to chase after the opinion you want. If you search long enough, you might find that opinion, but remember that there is usually value to consensus among the opinions you’ve received. Outlying opinions should be treated cautiously.

How to find a second opinion?

Ask your primary care provider (PCP). For patients who are fortunate to have a PCP, this may be the best source of a recommendation about how and where to seek a second opinion. Your PCP will know the local medical landscape. In many cases, he may have referred you to the specialist for your first opinion. But he will also know which doctor to suggest next, whether that’s another doctor in your community or one that’s farther away.
Ask your specialist. You can certainly ask the specialist who provided your first opinion. Some specialists will be more helpful than others when it comes to identifying a good choice for a second opinion. You may find that it’s easiest for your current specialist to suggest a partner who might also take a look at your situation.
Do some (online) research. There’s a lot of information online about specialists who you might visit for a second opinion. Perhaps there’s too much information. It can sometimes be challenging to sift through all of this information and make judgements about its quality. You may find that you will need to travel some distance to see a particular specialist. The danger here, though, is in not understanding the medical details sufficiently to select just the right doctor. And sadly, sometimes if you choose the wrong type of specialist, this may not become obvious until after you’ve invested in a visit. Another approach may be to select a large medical institution and have that institution help with finding just the right doctor to see you after they get some information from you and perhaps gather some medical records.
Word of mouth. At first, word of mouth may sound like a great way to find a doctor for a second opinion. Indeed, you may have friends or family that could suggest a doctor that they’ve seen and liked. The challenge here is that it can be difficult to find just the right doctor unless your family or friends have the exact same medical problem that you do.

Doctors get second opinions, too

Sometimes doctors obtain second opinions without their patients even knowing. This is just good practice. In this situation, the process may happen behind the scenes. Your doctor may share your particulars with a colleague to ask for help in settling on a diagnosis or settling on the best treatment. Your surgeon may ask a colleague to join him in the operating room to help decide what to do with an unexpected finding. Your pathologist may “send out” your biopsy specimen to get an additional opinion from a center of expertise. These sorts of second opinions are everyday occurrences.

When to change doctors

We should wrap up with talking about when to change doctors. So far we’ve been talking about getting additional, or second opinions. Most often, this is done with the intention of continuing to receive care from your first doctor. But what if you’d like to change doctors? There’s nothing wrong with wanting to receive your ongoing care from the doctor who gave your second opinion. That’s your decision and your doctors should understand making a change like that. I suggest that straightforward discussion with your doctors is the best way to make such a change.

Finally, let me mention two particular situations where you should consider finding a new doctor:

When you are concerned about honesty, transparency, or communication with your current doctor.
When you have reasonable concern about experience on the part of your doctor, clinic, or hospital.

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What Can I Do to Help?

February 10, 2018 By Larry Creswell, MD 8 Comments

I get hundreds of comments here at the blog and hundreds more emails each year looking for help of all sorts. This brings both joys and challenges!

Let me head off some of the disappointment that may come when I’m not able to offer help from afar and lay out the few ways in which I might be able to help….and the many ways in which I can’t….

Ways I can help:

Provide written blog posts that help educate about issues related to heart health and athletes. I’ll try to do more writing in 2018 and I can always use suggestions for topics that may be of interest.
Provide an opportunity for readers to comment on my blog posts. I’ll approve comments that help inform my audience and I’ll approve comments that ask straightforward questions. I’ll also approve comments where one reader responds to another reader, so long as it is for the purpose of sharing experiences or useful information.
I can sometimes direct readers to other useful sources of information or support groups….but not always.
I can always suggest that you consult your doctor(s) for medical advice.
I’m happy to see new patients at my office in Jackson, Mississippi. I am an adult heart surgeon, so my wheelhouse includes problems like heart valve disease, coronary artery disease, congenital heart problems that manifest as an adult, heart failure, certain arrhythmias, aortic diseases (including dissection, aneurysm, associated bicuspid aortic valve). But I’m also happy to see “healthy” patients for the purpose of checkups and cardiac screening and to work with my cardiology colleagues to evaluate athlete patients with the whole gamut of heart problems.
I can speak to your group on issues related to heart health and athletes.
I can speak with reporters or media outlets that are interested in stories about athletes and heart health. I enjoy helping to “get the word out.”
I can associate with other medical professionals or scientific investigators who are working on projects to help better understand athletes and heart problems.
Using my blog, and also through other networking, I can share helpful resources for athletes with heart problems.

Ways I can’t help:

I can’t be your doctor from afar. And since I can’t be your doctor from afar, I can’t provide medical advice. If we haven’t met, my advice probably wouldn’t be very good, anyway. Your best source for medical advice will be your own doctor(s) who are familiar with the particulars of your situation.
I can’t help you find a doctor in your hometown….unless you live near my hometown of Jackson, Mississippi.
I don’t endorse, contribute to, or advertise charitable organizations on the basis of online contact, regardless of how worthwhile the cause may be.
I can’t connect athletes with my patients for the purpose of networking. As an alternative, though, I can sometimes direct an athlete to an online support group of athletes in similar circumstances, where helpful networking may be possible.
Except in very unusual circumstances, I don’t offer my services as an expert witness in legal proceedings.
I am not interested in opportunities for advertising at my blog.

A Preseason Check-up (Specifically for Men)

February 5, 2018 By Larry Creswell, MD Leave a Comment

This is the time of year I get inquiries about pre-season medical check-up’s. I’ve written previously on this subject, including how to find a doctor in your area. I’m frequently asked, though, exactly what type of check-up is needed. Here’s my take.

Today, let me focus specifically on adult male recreational athletes. I’ll deal specifically with women in a follow-up post.

First, in terms of screening adult recreational athletes for sports-related heart risks, adult men are the group where we might expect to get the most “bang for our buck.” We know that men account for the vast majority of victims of sports-related sudden cardiac death, not only in large populations involving all types of sports, but also in very specific sports such as long-distance running and triathlon. There’s a very real reason to be looking for hidden heart disease in male athletes.

Second, in contrast to women, “healthy” men in their 20’s, 30’s, 40’s, and even 50’s are unlikely to make periodic visits to the doctor (except for injury) and very often do not have a current primary care provider (PCP). It may have been years—perhaps back to high school or college—that many men last had a complete physical exam in some context other than for a musculoskeletal injury, which typically requires a rather narrow focus. As a result, there’s often been little opportunity for discussion between adult male recreational athletes and a healthcare provider about any heart risks associated with sports participation.

Let me share how I would approach a pre-season check-up for an adult male recreational athlete who does not already have a PCP….

Although I’m a heart specialist, here I would need to put on my generalist hat to make the most of the encounter.

I would have 3 goals:

Identify any cardiovascular conditions that required further evaluation or treatment as well as any risk factors for future heart disease that could (and should) be modified;
Make an assessment of the patient’s cardiovascular risks of exercise in order to offer appropriate advice about safe forms of exercise; and
Identify any non-cardiovascular conditions that required follow-up with another doctor.

Before the Office Visit

One of the most important parts of a check-up is sharing what we call the “medical history,” an accounting of everything medically-related that’s already happened to a patient. This would include:

Past medical history (childhood illnesses, adult illnesses, surgical or other procedures)
Immunizations
Injuries
Medications and supplements
Allergies
Family history (illnesses that run in the family)
Personal and social history (smoking, drinking, sexual activity and habits, substance use/abuse, work history, travel history)
Review of symptoms (yes/no answers to a long list of questions about current symptoms).

In addition, I would also want to collect information about insurance coverage, the names and contact information for any other current and previous medical providers, and an outline of an athlete’s current exercise habits.

Depending upon the complexity of a patient’s situation, gathering all of this information could be rather time-consuming. So, in order to make the most of our available face-to-face time at the upcoming office visit, I find it helpful to collect as much of this information as possible well ahead of the office visit. I like to use 2 forms:

A general purpose medical history form such as the Health Care Consumer Questionnaire.
American Academy of Family Physicians Preparticipation Physical Evaluation forms. These forms are used ordinarily for secondary school-based screening programs, but I am fond of the first page of the History Form, which asks a series of questions (#5 through #16) related specifically to heart risk. I ask patients to complete items #1 through #51 on the first page and to discard the other pages.

When I’ve received these completed forms, I would review them and consider the possible need to gather additional information ahead of the office visit such as:

records from other physicians or hospitals
results from any heart-related diagnostic tests that may already have been completed (eg, ECG, chest x-ray, echocardiogram, Holter monitor, stress test, laboratory tests, pulmonary function tests, carotid Doppler studies, coronary calcium scoring CT scan).

Lastly, I would make a determination about any new diagnostic testing that may be helpful on the day of the office visit and schedule those tests, if any, for the morning of the office visit. If I think such testing will be helpful, I would have a telephone call with the patient ahead of the visit to explain the need for these tests.

At the Office Visit

I would plan for an office visit of approximately 45 to 60 minutes.

The first portion of the office visit is devoted to an interview. I generally spend half of the visit time on the interview. We often say that the medical history provides 80%+ of the clues to diagnosis.

First, I ask what motivated the patient for wanting the visit. There are many possible motivations. Next, we would have a chance to review the information that had already been provided about the patient’s medical history. I would take the time to clarify and better understand anything in the history that was specifically related to the heart. We would focus on those history items and on any symptoms related to exercise. I would finish by asking the patient if there were any additional, specific concerns that we should address at this visit.

The second portion of the office visit is devoted to a physical exam. Here, I would offer a complete, head-to-toe physical exam, but with special emphasis on the cardiovascular system. The exam would include:

Measurement of the height, weight, and vital signs (blood pressure, heart rate, respiratory rate, temperature)
Screening neurologic exam
Examination of the head, neck, ears, eyes, nose, and throat
Respiratory exam
Cardiovascular exam (heart, carotid arteries, abdominal aorta, arteries of the arms/legs)
Abdominal exam, including check for hernias
Genito-urinary exam
Rectal and prostate exam, in men older than 40 years
Examination of the skin

The third portion of the exam is devoted to a discussion, or wrap-up. Here, we would discuss my findings from the medical history and the physical exam and my assessment of the patient’s overall and heart health.

For the majority of patients–those who do not have any heart-related symptoms or any abnormal physical exam findings–we would spend some time discussing the utility of screening tests such as ECG, echocardiogram, laboratory testing (eg, fasting glucose, fasting serum lipid levels), or stress testing, along with the advantages, disadvantages, and potential costs. Together, we would decide if any of these tests would be helpful. There is a place for such screening tests, but only with thoughtful discussion first.

For other patients, we might identify some new heart-related condition–or at least the possibility of one. As examples, we might find that the blood pressure is elevated or note the presence of a heart murmur. In this situation, we would talk about what sort of diagnostic tests might be needed to further clarify a problem and perhaps what treatment(s) would be needed for any conditions we discovered. Needless to say, there are many potentially useful tests, depending upon the patient’s circumstances, so we won’t go into detail here. In the case of potential inherited disorders, we might need to consider evaluating other family members as well.

In either situation, if additional testing were needed we would make a plan for getting those tests completed. We would also plan for how I would share those results with the patient (eg, by telephone or during a follow-up visit). I would ordinarily make plans to visit with the patient again to discuss the results of any important testing and to resume with our wrap-up once all of the important information was at hand. If more specialized heart care were needed, I would discuss referral to the appropriate specialist (eg, general cardiologist, electrophysiologist, interventional cardiologist, specialist in congenital heart disease) and, in some cases, I would turn over the patient’s care to that specialist.

Next, we would discuss how the patient’s overall and heart health related to his/her plans for exercise and sports participation. Together, we would settle on a list of activities that would be “safe” and, likewise, settle on a list of any activities that should be avoided. We would talk about potential warning signs of heart troubles and how to be vigilant for these. If the patient required a “doctor’s letter” or some sort of pre-participation form to be completed, we would go over that form together and review its requirements. I often complete such letters or forms and return them to the patient by mail sometime after the visit.

We would then make an inventory of any other medical problems (that were not heart-related) that needed follow-up and work together to settle on an appropriate action plan. Examples of such medical problems could include: colon cancer screening in men older than 50 years, that would require a gastroenterologist visit; eyesight troubles that might best be evaluated by an ophthalmologist; periodic screening for sexually transmitted illnesses, which might best be accomplished by a primary care physician; dental care which would best be provided by a dentist; and depression, that might best be evaluated by a psychiatrist. The list of possibilities is virtually endless; this is why there can be tremendous value in having a PCP.

Before we finish the wrap-up, I would take time to have a discussion about any questions or concerns the patient brought. I usually suggest that patients bring a written set of questions that we can answer these one by one.

Finally, I would make a recommendation about when the patient should next be seen for another check-up. For “healthy” patients–those without chronic medical conditions that require monitoring–I generally suggest a check-up every 3 years for men <40 years old, every 2 years for those 40-50 years old, and every year thereafter.

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More on Triathlon Fatalities–A Scientific Report

September 18, 2017 By Larry Creswell, MD 4 Comments

Readers here at the blog will know that I’ve had a long-standing interest in triathlon fatalities. My interest was originally sparked by media reports and the paradox that seemingly healthy and fit triathletes might die on race day.

I was involved with an internal review of this problem at USA Triathlon (USAT), the governing body for the sport of triathlon in the United States. In 2011, that task force issued a formal report and set of recommendations for athletes, event organizers, and USAT itself. Those written recommendations are still valuable today as we work to reduce the number of triathlon race-related fatalities.

In this week’s edition of Annals of Internal Medicine, I joined with Drs. Kevin Harris and Barry Maron from the Minneapolis Heart Institute in reporting on “Death and Cardiac Arrest in U.S. Triathlon Participants, 1985-2016: A Case Series.” In this scientific report, we’ve gathered information about 122 athletes who died and another 13 athletes who suffered cardiac arrest but survived during triathlon races in the United States over the past 3 decades. This is, by far, the most comprehensive scientific report on this subject.

Special thanks go to the leadership at USAT which recognized the importance of this issue, has been proactive in working to reduce the number of race-related fatalities, and was extraordinarily helpful to our investigative team as we assembled the information for our new report.

The Important Observations

Victims were 47 +/- 12 years old
85% were men
Almost 40% were first-time triathlon participants
There were no elite or professional athletes among the victims
The overall rate for fatalities or cardiac arrest was 1.74 per 100,000 participants (2.40 for men, 0.79 for women). For comparison, the rates of cardiac arrest (including fatalities) are approximately 1.0 per 100,000 participants in marathons and 0.3 per 100,000 participants in half marathons.
The fatality risk in triathlon increases exponentially with age; the fatality rate was 18.6 per 100,000 participants among men 60+ years old
Fatality rates were similar for short, intermediate, and long-distance races
The majority of deaths (74%) occurred during the swim segment; smaller numbers of deaths occurred during the bike or run segments or after finishing the race
Among 22 fatalities occurring during the bike segment, 15 were due to traumatic injuries
At autopsy, clinically relevant (but presumably previously unrecognized) heart/vascular disease was found in many victims

A Recipe for Doing Better

We should focus on two strategies for reducing the number of fatalities: 1) we should work to prevent incidents of race-related cardiac arrest and 2) we should work to improve the survival rate for any such victims of cardiac arrest. Athletes, physicians, event organizers, safety personnel, and sport governing bodies can all play an important role.

Athletes should:

Make certain that their participation in a particular race is in keeping with their health, both chronic and acute, as well as their ability and preparation.
Consider their heart health before participating. This may be particularly true for first-time participants and for men who have reached middle age. For older men, testing for “hidden” coronary artery disease (CAD) or other forms of cardiovascular disease may be appropriate.
Assess their health on race day and consider not racing if they are “sick.” Symptoms, particularly systemic symptoms like fever, are related to DNF rates in other sports settings.
Be prepared for the rigors of a triathlon swim. It is important to be a capable swimmer and to have practiced open water swimming in advance of the race.
Think to STOP at the first sign of medical troubles (unexplained shortness of breath, chest pain/discomfort, or light-headedness), particularly during the swim segment.

Physicians should:

Be aware of the risks of participating in triathlon and be in a position to counsel their athlete patients about those risks in the context of the patient’s specific health situation.
Consider the potential value of cardiac screening, particularly for occult CAD in men who have reached middle age. Evidence-based screening protocols are not yet available, so an approach will need to be individualized. In most cases, an evaluation of the traditional risk factors for CAD would be appropriate and in some cases, additional testing such as calcium-scoring cardiac CT or stress testing may be appropriate. Athletes who are just beginning an exercise program should receive special attention in this regard.

Event organizers should:

Develop a robust safety plan, particularly for the swim segment, that enables prompt (near instantaneous) identification of a lifeless victim, and then rescue of that individual to a location where CPR, defibrillation, and advanced life support can be provided.
Have a communication system for all individuals involved in race-day safety.
Rehearse the safety response to a lifeless victim, especially for the swim segment.

Race-day safety officials should:

Be trained in CPR and use of the AED.
Be familiar, through rehearsal, with the communication and safety plans.

Sports governing bodies should:

Provide education for athletes, event organizers, medical directors, and volunteer safety officials about life-threatening race-day emergencies.
Develop rules and sanctioning requirements that promote athlete safety.

Reference:

Harris KM, Creswell LL, Haas TS, Thomas T, Tung M, Isaacson E, Garberich RF, Maron BJ. Death and cardiac arrest in U.S. triathlon participants. Annals of Internal Medicine 2017 (in press).

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