Athletes & preventive care

Triathlon Fatalities: 2013 in Review

December 30, 2013 By Larry Creswell, MD 6 Comments

With the 2013 triathlon coming to a close here in the United States, I thought I’d provide an update about triathlon fatalities. I’ve been working on a talk for next month’s USA Triathlon (USAT) Race Directors Symposium about this issue and it gave me the opportunity to gather some new data about the 2012 and 2013 seasons. I’ll also reflect on the media coverage of this issue in 2013, point you to some resources that may be helpful for athletes and event directors, and share my thoughts about the challenges and opportunities that remain.

The USAT 2012 Report

It’s been just over a year since USAT released its final report on event-related fatalities from 2003-2011. In addition to providing information about 45 fatalities during that 9-year period, the report concluded with a set of recommendations, in a framework of shared responsibility, for athletes, race directors, and USAT itself. The report is worthwhile reading for everybody in our triathlon community. I still believe that all of the reasonable opportunities for reducing the number of fatalities are included in those recommendations.

Media Attention in 2013

The issue of triathlon fatalities continues to receive attention in the media. Each of the fatalities in 2013 drew the attention of the local media and some garnered attention in the national media as well. The death of Ross Ehlinger at this year’s Escape from Alcatraz Triathlon in March received the most attention, with widespread reporting in the national media. I was at the race that day and shared some of my thoughts in a previous blog post. There was a fair bit of criticism in the media about issues such as particularly difficult water conditions for the swim that day, unusually cold water temperatures, an earlier-than-usual event date, and a large number of swimmers who required rescue or repositioning during the swim portion of the event. We learned months later from autopsy information that Ehlinger had significant, unrecognized coronary artery disease. Early speculation in that regard turned out to be correct.

The issue also received national attention in May in a short report in USAToday entitled Swimming Deaths Trouble Triathlon Officials. That report included a table (essentially from the USAT report) that recognized again the large proportion of fatalities that had occurred during the swim portions of events over the years. The article highlighted the stories of several athletes who died during the 2012 season and offered commentary by USAT CEO, Rob Urbach, and Dr. Rudy Dressendorfer about potential mechanisms and causes.

ESPN took an interest in this issue and worked with USAT to gather information during the early part of the 2013 season. In October, long-time ESPN reporter Bonnie Ford wrote an article enetitled Trouble Beneath the Surface, that examined in some detail the facts surrounding swim-related fatalities in triathlon. The article raised questions not only about athlete preparation for events but also about safety-related preparations by event organizers. As part of its Outside the Lines program, ESPN also released a short video report by T.J. Quinn that paralleled Bonnie Ford’s reporting. I was able to join Ford, Quinn, and cardiologist John Mandrola, MD, as a panelist for that broadcast which is available now as an archived podcast. I wrote about the experience in more detail here at the blog. The discussion was pretty short, but we had a chance to talk about both athlete and event organizer responsibilities for improved safety. I’ll thank ESPN for taking on the issue and drawing our attention to opportunities for improvement in race-related safety.

The public scrutiny this year wasn’t directed only at triathlon, though. The Tough Mudder series of races came under criticism for the general health risks of participation. An article in the NY Daily News was typical of the reporting about seemingly high rates of athlete injuries and emergency room visits. The death of an athlete at an April race at the Walk the Plank obstacle, presumably because of drowning, also received considerable attention in the media. This article in Outside Magazine is typical of the reports that raised concerns about safety planning and inadequate lifeguard resources for the large number of participants.

The 2012 and 2013 Fatalities

The USAT 2012 report detailed the event-related fatalities for 2003-2011. We’ve had 2 seasons since then. The fatalities in 2012 and 2013 occurred against a backdrop of continued strong participation numbers for the sport in the United States.

In 2012, there were 4,310 sanctioned events where there were 565,325 finishers. Fourteen athletes died, a fatality rate of approximately 1 per 40,000 participants. It appears that 2012 had the highest fatality rate in the past decade. Thirteen athletes died during the swim portion and the remaining athlete died during the bike portion of an event. These athletes included 13 men and 1 woman who ranged in age from 34 to 69 years.

In 2013, through November, there were 4,084 sanctioned events where there were a total of 512,972 finishers. Eight race participants died, a fatality rate of approximately 1 per 64,000 participants. Five athletes died during the swim, 2 died during the bike, and 1 died during the run portion of an event. These athletes included 6 men and 2 women who ranged in age from 31 to 70 years.

An additional athlete died in 2013 during an event-sponsored practice swim the day before a sanctioned race which was then cancelled because of the fatality. There has been ample discussion these past couple years about the value of a swim warm-up immediately before a race. No doubt, this can be helpful in many ways. But we must remember that sudden cardiac death can occur at any time–not only during a race. In fact, the vast majority of sports-related sudden cardiac deaths each year occur outside of competition.

From press accounts, we know of 1 survivor of cardiac arrest during the bike portion of the August 4, 2013 edition of the Cleveland Triathlon. Todd Rains, a 44-year-old man, collapsed during the bike portion of the event, received prompt CPR by fellow participants, and was successfully resusciated. The number of such incidents at triathlons remains largely unknown. Given that the survival rate for out-of-hospital cardiac arrest is thought to be <15%, I suspect the number is small.

Updated Overall Statistics

With the addition of the 2012-2013 data to the previously reported 2003-2011 data, we now know there have been 68 event-related fatalities over an 11-year period. That span includes nearly 32,000 events with more than 4 million participants. Narrowing the focus a bit, we might include only the 65 athletes who died at a race, and exclude the 1 spectator death, 1 fatality at a clinic rather than a race, and the 1 death during the practice swim. In terms of race-related incidents, the approximate fatality rate since 2006 is approximately 1 per 65,000 participants.

If we include all 68 athlete fatalities, 49 (72%) occurred during the swim, 11 (16%) during the bike, 4 during the run, 2 after the race, 1 in a spectator, and 1 in a pre-race practice swim.

Coverage in the Triathlon Media

The issue of race safety garnered the attention of the triathlon media in 2013. I’d like to thank the various editors.

In the April, 2013 issue of Triathlete Magazine, Warren Cornwall, a triathlete, wrote an article entitled What Lies Beneath. That article is now available online with a new title, “Are You Fit to Race Triathlons?” Cornwall’s interest in triathlon race safety was spurred by his participation in the 2012 USAT National Championship races in Burlington, Vermont, where Richard Angelo died during the Olympic distance race. Cornwall writes about the potential causes of athlete fatalities and shares his personal story of undergoing a cardiac evaluation. He offers a good sidebar on the pros and cons of various diagnostic tests to determine “Are You Fit to Race?”

In the 2013 edition of New Zealand’s Iconic Adventures magazine, Mark Banham wrote an article entitled, “Heart of the Matter.” He addresses the issue of sports-related sudden cardiac death, starting with the ancient story of Phillipdes and then turning to modern endurance athletes. He offers a set of heart health tips that will be useful for athletes.

The November/December issue of Inside Triathlon featured an article by Torbjorn Sindballe, entitled “From the Heart.” Sindballe, as you may know, retired from the sport of triathlon in 2009 because of problems related to a heart condition known as bicuspid aortic valve (BAV). He was born with an aortic valve with 2, rather than the normal 3, leaflets. With time, individuals with BAV are predisposed to having problems with leakage–or regurgitation–of the valve as well as enlargement of the nearby aorta. Sindballe developed both of these problems. He describes the diagnosis of his condition in 2005 and talks about how this impacted his elite triathlon career. He includes 4 tips for a long and healthy life: 1) react immediately to serious symptoms; 2) get a check-up; 3) chase your dreams, but respect your body; and 4) change triathlon’s overachieving culture. All good advice.

In the December online edition of Triathlete Europe, Drs. Merghani, de Meyer, and Sharma wrote an article, entitled “Cardiac Screening: Heart Health and Triathlon.” Written by a group of authors who are among Europe’s foremost experts in sports cardiology, this article addresses some of the underlying cardiac causes of sports-related sudden cardiac death and talks about the value in cardiac screening for endurance athletes.

Resources for Athletes

A couple new resources for athletes in 2013 deserve mention.

As part of its SwimSmart initiative, World Triathlon Corporation (WTC) produced a short video on swim safety narrated by Paula Newby Fraser. Fraser details a 10-point safety checklist as triathletes prepare for their next triathlon swim. This checklist is applicable to all triathletes–not just those participating in Ironman events. Ten minutes listening to this video might save your life.

USAT has a very active webinar program. Their listing of upcoming as well as archived webinars is available here at the USAT website. Earlier this year I hosted a webinar on Heart Health and Endurance Sport, a 45-minute look at some of the heart issues that are faced by endurance athletes. A portion was devoted to the topic of cardiac screening of athletes. Best of all, it’s free!

I’ll mention that I’m toying with publishing a very short eBook that deals with triathletes, open water swimming, and safety. The book would answer the question: What can I do as an athlete to make my next triathlon swim as safe as possible? I’d like to reach as many triathletes as possible and I’d like to leave readers with a simple, ~10-point plan. Please let me know if you have advice, suggestions, etc.

Resources for Race Directors

Several developments on the race director front in 2013 deserve mention.

USAT issued a new set of Recommendations for Multi-sport Age Group Swim Segments regarding water temperature. I’ve written about this issue in a previous blog post. This is a step forward, bringing USAT into the collection of governing bodies that have thoughtfully considered the issue of water temperature and athlete safety. All of us in the triathlon community will need to become familiar with the new recommendations. Both athletes and event directors should be familiar with the safety issues and possibilities of hypothermia or heat-related illness at the extremes of water temperatures. I understand that USAT will be rolling out infomational pieces as we move into the 2014 race season.

I mentioned at the top of this post that I’m speaking at the upcoming USAT Race Directors Symposium. This year’s event will be held as a virtual, rather than an in-person, symposium. Check out the details at the USAT website.

WTC and Rev3 Triathlon each rolled out water safety initiatives this year. I wrote about the details in a previous blog post at the start of the season. I mentioned the WTC water safety video earlier. Let me also mention a collection of 4 articles on athlete swim safety written by professional triathlete, Malaika Homo, for Rev3. They’re good reading. I know that the WTC and Rev3 initiatives got a lot of attention this year both inside and outside of the triathlon community. I hope that these organizations will report back about their successes and their thoughts about a course forward.

There are several recent and upcoming USAT webinars on the topic of race safety, and that are targeted to event directors: Setting Up Your Medical Team for a Long Course Event–J. Rizzo; Emergency Management Plan Case Study: Preparing for the Unexpected–E. Sarno; Preparing for the Storm: A Look into Crisis Management–B. Davison; and 9-1-1: Preparing for Emergencies at Your Event–J. Flint.

USAT is planning for a first annual conference for medical professionals in May, 2014 at the Olympic Training Center in Colorado Springs. Details should be available soon. The 2-day conference will be targeted at medical professionals with involvement in multi-sport event planning and management. Athlete safety will figure prominently in the program. I’d encourage event organizers to pass this information along to their events’ medical directors and staff.

Lastly, I’ll point out an interesting panel session at the upcoming Triathlon Business International conference next month in Los Angeles. Targeted at race directors, the January 27th panel session on the “Hot Topic” of water safety will include: Bill Burke, race director; Bonnie Ford, ESPN reporter; Dan Ingalls, National Marine Safety Center; Captain Danny Douglas, Venice Beach Lifeguard Operations; and Charlie Patten, Rev3 Triathlon. This should be a lively session!

Challenges and Opportunities

Our challenge remains to reduce the number of athlete fatalities at triathlons. Athletes, event organizers, and USAT all have a role to play. I’ve been encouraged this year by the level of engagement about this issue. As a community, our awareness may never have been greater. But there’s obviously more work to do. Even a single fatality is one too many. So here ‘s what I’d like to see in 2014:

Education and awareness. I hope that the issue of race safety will continue to receive attention by the triathlon media in 2014. I’m convinced that athletes want information that may help them train for and compete in triathlons safely. Let the various editors know that race safety continues to be an important issue. USAT and the other relevant governing bodies can also help with print, video, webinar, or in-person educational activities. Topics related to heart health, cardiac screening, and athlete preparation for open water swimming would appear to be the important topics for athletes. If you have expertise in these areas, volunteer to help USAT in their efforts, volunteer to help your local race director, or offer to speak to your local tri club. I know they’d be happy to hear from you. I also hope that the media outlets will work hard to find and share the good stories–the stories of athletes who had major medical problems at events, but overcame them and are back to training and competing. We don’t hear enough of those stories.

Further investigation. USAT is partnering with Kevin Harris, MD, from the Minneapolis Heart Institute to investigate in further detail the medical histories, initial treatment, and autopsy information for athletes who’ve died at triathlons in the past decade. This is a big undertaking. I’m hopeful that this investigation will shed additional light onto the causes of the athlete deaths and suggest additional steps we might take in the future to make racing more safe. As part of that work, we will be trying to identify survivors of cardiac arrest at races. If you know of such an athlete, please let me know. Often, there is a lot to learn from the so-called near misses. I’m hopeful that much of this work will be completed in 2014 and that I might be able to report back at this time next year with some highlights. There are probably countless areas of worthwhile investigation when it comes to athlete safety and multi-sport events. If you’re an investigator with an idea for a potential study, I’d urge you to be in touch with USAT. Maybe it’s a project on athlete pre-race anxiety. Or, perhaps it’s a project related to swimming-induced pulmonary edema (SIPE). If there’s an interest in improving athlete safety, I bet they’d be receptive.

Safety planning. Event organizers must continue to work on planning the safest possible events. Given the information at hand about athlete fatalities, safety planning for the swim portion of events should obviously receive special attention. It’s critical that safety plans and lifeguarding resources allow for the almost immediate identification of a lifeless swimmer and then rescue so that CPR and early defibrillation can be provided. It seems simple, but it’s logistically complex. My hope for 2014 is that the event director community will work together to develop educational materials and best practices that can be shared widely. USAT could facilitate this exchange.

I remain optimistic that, together, we can make a difference in 2014.

Book Review: The Exercise Cure by Jordan D. Metzl, MD

November 26, 2013 By Larry Creswell, MD 4 Comments

Dr. Jordan Metzl’s second book, The Exercise Cure, makes its debut next month. I love the title. Dr. Metzl is right when he advocates exercise as “a doctor’s all-natural, no-pill prescription for better health & longer life.”

You might think that the importance of exercise is obvious. Yet nearly 70% of the adult American population is overweight, including more than 30% who are obese, and only the minority get the 150 minutes of weekly exercise recommended by the American Heart Association and other public health organizations.

Some will remember Dr. Metzl from his first book, The Athlete’s Book of Home Remedies. I thought this book was pretty clever. In both of these books, he draws from his career in sports medicine and his long career as an endurance athlete. He currently practices at the Hospital for Special Surgery in New York and makes frequent media appearances. You may know him from the NBC’s Today show.

The book is organized into four sections. In the first, Dr. Metzl lays out the scientific rationale for regular exercise. He follows in the second section by describing how exercise impacts our health in a variety of health areas, including the brain and psychological well-being, heart health, musculoskeletal problems, and cancer, among others. In the third section, Metzl shares a day-by-day, month-by-month plan for how to make exercise part of daily life. Individuals who’ve already been exercising can join into the program at the Silver level of the three-tiered program. In the last section of the book, Dr. Metzl offers some very practical advice about nutrition and diet.

The book will be an interesting read for anybody who wants to learn more about the scientific underpinnings of the relationship between exercise and our health. But the book will be most valuable as a source of inspiration for somebody who’s currently on the couch. This would make a great gift for somebody who’s considering becoming more active.

With a release date of December 10, 2013, the book is available now for pre-ordering in hardcover or e-book at Amazon.

Other Book Reviews:

1. Heart 4-1-1

2. General Medical Conditions in the Athlete

Debate Continues on Cardiac Screening for Youth Athletes

November 25, 2013 By Larry Creswell, MD Leave a Comment

This post is for the parents out there. I don’t have many youth athlete readers here at the blog, but I’ll bet there are more than a few parents.

We’re all familiar with the sad stories of young athletes who die suddenly while playing their sports. According to most estimates, about 1 young athlete per 50,000 to 100,000 per year will have sudden cardiac death during practice or competition. These incidents often receive a great deal of attention in the media. They also have a lasting impact on families, schools, and communities that struggle afterwards to deal with the tragedy.

The medical community also struggles with this issue. There are very legitimate differences of opinion about what best to do. We know that most of these young athletes die from some sort of unrecognized heart problem, so there’s an obvious motivation for cardiac screening programs to find these heart problems before a young athlete dies as a result. Yet we also know that such screening programs are costly in both monetary terms and in the needed resources. We also know they’re not foolproof.

In last week’s November 21, 2013 edition of the New England Journal of Medicine, a Clinical Decisions feature was devoted to the topic of “Cardiac Screening before Participation in Sports,” focusing on school-aged athletes. This feature asked experts in the field to respond to 2 related questions.

The first question asked: Should young athletes be required to undergo cardiac screening before participating in sports?

Dr. Sanjay Sharma, a cardiologist from the St. George’s University of London answered YES.
Dr. Mark Estes, a cardiologist from Tufts University in Boston answered NO.

The second question asked: If an athlete does undergo screening, should the screening involve only a history and physical examination, or should electrocardiography (ECG) also be required?

Dr. Victoria Vetter, a pediatric cardiologist from Children’s Hospital in Philadelphia, recommended AGAINST the ECG.
Dr. Domenico Corrado, a cardiologist from the University of Padua in Italy advocated FOR the ECG.

The position statements are intended for a physician audience, but even non-medical folks will be able to read them and learn something. Take a moment to read what these doctors say. In just a few short paragraphs, each summarizes the important arguments. You won’t find a better summary of the arguments.

The journal also has an online poll for readers to weigh in on the issue. The poll asks readers to consider the expert opinions and then answer the 2 questions for themselves. I answered YES for screening and YES for an ECG. As I sit here writing on Sunday afternoon, nearly 900 readers have responded to the poll, with the following results:

18% voted for requiring NO screening
23% voted for screening with medical history and physical examination alone
57% voted for screening that also included an ECG.

At the level of schools, communities, and states, there is increasing awareness about the issues surrounding cardiac screening for young athletes. Some have created screening programs that are available to athletes, often at little or no cost. In the end, though, in most communities parents will need to make appropriate decisions about cardiac screening for their children. Be informed.

2. Ask the experts: Pre-participation heart screening for adult endurance athletes.

New ACC/AHA Heart Health Guidelines and Implications for Athletes

November 21, 2013 By Larry Creswell, MD Leave a Comment

Last week the American Heart Association (AHA) and American College of Cardiology (ACC) released a new set of Guidelines to Reduce Cardiovascular Risk. In just a few short days, these Guidelines have received a great deal of attention–and a fair bit of controversy–in medical and scientific circles. They’ve also caught the attention of the popular media and have generated a lot of discussion.

Let’s take a moment to remember that heart disease remains the #1 killer of both men and women in the United States. About 600,000 deaths annually are due to heart attack and another 130,000 are due to stroke. There is obviously ample reason to care about heart disease prevention–and that is what these new Guidelines are all about.

The Guidelines are targeted at primary care providers–the doctors and other medical professionals who provide routine, long-term care for their patients. All of us should be aware of these Guidelines, though, because they will shape the way the medical community approaches heart disease prevention for years to come.

Let’s take a look at the Guidelines and how they relate to athletes, specifically.

The Guidelines

The new Guidelines have been offered electronically online in preliminary form. They will soon be published in the organizations’ medical journals, Circulation and the Journal of the American College of Cardiology.

There are actually 4 separate Guidelines:

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
2013 ACC/AHA Guideline on Lifestyle Management to Reduce Cardiovascular Risk
2013 ACC/AHA Guideline for the Management of Overweight and Obesity in Adults.

These Guidelines have been long in the making. With efforts that began in 2008, each of the Guidelines was developed by a panel of experts which conducted a thorough review of the relevant scientific evidence that had been accumulated through 2011. In the end, the panels reached consensus about conclusions that could be drawn from the evidence and constructed the Guidelines to help guide primary care providers in the care of their patients.

As a whole, the Guidelines aim to match the intensity of prevention efforts to an individual’s absolute risk of future atherosclerotic cardiovascular disease (ASCVD).

Guideline #1–Assessment of Cardiovascular Risk

For a variety of heart-related treatment decisions, it has been important to have an estimate of a patient’s future risk of having a major cardiovascular event such as a heart attack (myocardial infarction, MI). Examples would include decisions about the type and intensity of treatment for elevated serum cholesterol or lipid levels, the use of aspirin for the prevention of a future MI, or the type and intensity of treatment for high blood pressure.

Several prediction tools have been available. The most popular tool is the Framingham 10-year risk score which was first proposed in 1998 and has been updated several times since. The Framingham risk score was modeled using data obtained over several decades from the Framingham Heart Study. The risk score is based on an individual’s age, sex, serum total cholesterol and HDL cholesterol, smoking history, systolic blood pressure (the upper number), and the use of medications for blood pressure control. The risk score predicts the 10-year risk of developing coronary heart disease (CHD)–heart attack, or MI. The Framingham risk score does not predict the future risk of other important cardiovascular outcomes such as stroke, mini-stroke or transient ischemic attack (TIA), or heart failure. Moreover, since this score was based on data gathered from only White populations, the Framingham risk score has always been criticized for its generalizability to other patient populations.

With the new Guidelines, we now have a risk calculator that applies to a much broader patient group that includes the U.S. White and African American populations from age 40 to 79 years. The expert panel developed new equations for the prediction of 10-year risk of developing a broader set of endpoints that now include the combination of nonfatal MI, CHD death, and fatal or nonfatal stroke. As a group, this set of endpoints is referred to as atherosclerotic cardiovascular disease (ASCVD).

The prediction equations are currently implemented in an Excel spreadsheet Risk Calculator that can be downloaded from the AHA or ACC websites. Users will see that their 10-year risk is based on their inputs of age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, use of blood pressure medication(s), diabetes, and smoking. The prediction equations are intended for the adults who do not already have known ASCVD.

In addition to the creation of the Risk Calculator, the expert panel made several recommendations about its use:

Traditional risk factors for ASCVD (age, sex, total cholesterol, HDL cholesterol, systolic blood pressure, use of blood pressure medications, and current smoking) should be assessed every 4-6 years in adults 20-70 years of age.
The Risk Calculator should be used every 4-6 years to estimate the 10-year future risk of ASCVD in individuals 40-79 years of age.
For patient groups other than non-Hispanic Whites and non-Hispanic African Americans, the equations for non-Hispanic Whites should be used.
If a treatment decision remains uncertain after the Risk Calculator is used, then additional factors such as family history of heart disease, serum C-reactive protein level (>2 mg/dL), coronary artery calcium (CAC) score from a cardiac CT scan (>300 Agatston units or >75th percentile for age), or ankle-brachial index (ABI) <0.9 may also be taken into consideration.
The value, if any, of using serum apolipoprotein B, chronic kidney disease, albuminuria, carotid artery intima-media thickness, or cardiorespiratory fitness as additional risk factors is not yet established.

Implications for Athletes

Many athletes will have a favorable risk profile. They will have a normal blood pressure, be non-smokers, and have normal values for the serum cholesterol and lipids. But even healthy athletes should take the time for periodic assessment of their cardiovascular risk factors starting at age 20. Ideally, this would be accomplished with the support of your doctor. But even without a doctor, athletes should remember to have the serum cholesterol and lipids checked every 4-6 years. Remember, too, that age alone is a risk factor–and none of us can escape the fact that we continue to age!

Middle-aged athletes often ask about the value of additional diagnostic testing to help quantify their future risk of CHD or even sports-related sudden cardiac death (SCD). And either alone, or in conjunction with their doctors, they pursue testing such as measurement of the serum CRP or a cardiac CT scan for CAC score. These tests should be used with discretion. They are most helpful when a specific treatment decision must be made (eg, deciding whether to start a new cholesterol-lowering medication) and the new Risk Calculator suggests that the decision could reasonably go either way.

Guideline #2–Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults

The second Guideline focuses on the use of cholesterol-lowering statin medications (eg, Lipitor, Zocor) to reduce cardiovascular risk. This new Guideline provides a fresh approach to the use of these cholesterol-lowering agents in the prevention of heart disease. The Guideline also recognizes that “lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies.”

Our former guidelines about cholesterol-lowering medications come from the National Institutes of Health and their National Heart Lung and Blood Institute (NHLBI) Adult Treatment Panel (ATP) III, last updated in 2004. These guidelines advocated the use of cholesterol-lowering medications for specific elevation levels of the LDL cholesterol and total cholesterol and specified absolute target levels for their reduction.

In contrast, the new Guideline recognizes that there is actually no credible scientific evidence to support the use of specific target levels for the LDL cholesterol or total cholesterol. Furthermore, the Guideline advises that non-statin medications do not provide acceptable ASCVD risk reduction to justify their use.

The expert panel identified 4 groups of individuals who benefit from statin medications:

Individuals who already have ASCVD
Individuals with elevation of the LDL cholesterol >190 mg/dL
Individuals 40-75 years old with diabetes and LDL 70-189 mg/dL
Individuals without ASCVD or diabetes who are 40-75 years old, with LDL 70-189 mg/dL and an estimated 10-year risk of ASCVD of 7.5% or higher.

The newly developed Risk Calculator is the tool that should be used to determine an individual’s 10-year risk of ASCVD.

In groups #1 and #2, the Guideline advises using high-intensity statin therapy that usually reduces the LDL cholesterol by 50% or more. In group #4, moderate-intensity statin therapy that usually reduces the LDL cholesterol by 30-50% is advised. In group #3, either moderate- or high-intensity therapy could be warranted, depending upon the patient’s 10-year risk of ASCVD.

About 25% of Americans already take these medications. With these new Guidelines, it is estimated that about 50% of African American men and 35% of White men in their 50’s would qualify for a statin drug. And similarly, 50% of African American women and 35% of White women in their 60’s would qualify. Category #4 (adults without ASCVD or diabetes who have a 10-year ASCVD risk of 7.5% or greater) is thought to represent about 30 million Americans. So obviously with full implementation of these guidelines, more Americans will be taking statin medications.

Implications for Athletes

Exercise has a very favorable influence on an individual’s lipid profile, lowering the LDL cholesterol and total cholesterol and raising the HDL cholesterol. Exercise also has a favorable influence on the blood pressure. These beneficial effects are taken into account in the Risk Calculator used to predict the 10-year risk of ASCVD.

There are athletes who fall into groups #1, #2, and #3 because they’ve already had a heart attack or stroke, or have severe elevation of the LDL cholesterol, or have diabetes. By and large, these are individuals who already have a reason to be taking a statin medication. The new Guideline is no different here.

With the new Guideline, group #4 is most interesting. I suspect there are many athletes who fall into this group, but who currently do not take cholesterol-lowering medications. Remember, this group now includes adults 40-75 years old with a 10-year ASCVD risk greater than 7.5%. We previously thought that a 10% risk threshold was needed to justify the use of statin drugs. Athletes in this group should have a discussion with their doctor about the use of statin medications to reduce their cardiovascular risk.

One of the known side effects of statin medications are muscle symptoms such as pain, tenderness, and cramping. In athletes with these symptoms it can sometimes be difficult to sort out whether the symptoms are due to the medication or to the athlete’s exercise routine. The new Guideline advises:

Establish a baseline related to muscle symptoms before starting a statin drug
Stop the medication if new muscle symptoms develop, to allow time for evaluation for other potential causes of the muscle symptoms
Restart the medication if no other cause is found, trying to identify a causal relationship between the statin drug and the symptoms. If that is the case, change to a lower dose of a different statin medication.

Guideline #3–Lifestyle Management to Reduce Cardiovascular Risk

The third new Guideline recognizes the role that dietary patterns, nutrient intake, and levels and types of physical activity play in the risk of ASCVD, particularly through their influence on the modifiable risk factors such as blood pressure and serum cholesterol and lipids.

For both lowering of the LDL cholesterol and for lowering the blood pressure, the Guideline recommends “a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats.” Examples of such diets are the DASH dietary pattern, the USDA Food Patterns, or the AHA Diet.

Additional recommendations include limiting saturated fat in the diet to 5-6% of total calories, reducing the percentage of calories from trans fat, and limiting sodium intake to 2,400 mg per day.

The Guideline recommends aerobic exercise for its beneficial effect on the LDL cholesterol and blood pressure, suggesting an exercise routine of 3-4 sessions per week, lasting ~40 minutes per session, and involving moderate to vigorous physical activity.

Implications for Athletes

There should be no real surprises with this Guideline.

Although there are advocates for many other particular diets, this Guideline recognizes that their benefit with regard to ASCVD risk reduction is not established. In some cases, these other diets may be good, but there are simply no studies to prove it.

The many health benefits of exercise are well established. Obviously, physical activity has a beneficial effect in terms of ASCVD risk reduction, but there are many other benefits as well.

Guideline #4–Management of Overweight and Obesity in Adults

The final Guideline addresses the management of overweight and obese adults. This Guideline was written in conjunction with The Obesity Society and is endorsed by a host of other national organizations.

The Guideline recognizes that in 2009-2s010, there were 78 million adults in the United States with obesity, a condition that is associated with high blood pressure, abnormal serum lipid profile, type 2 diabetes, CHD, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and some forms of cancer. The new Guideline reaffirms our current definitions of body mass index (BMI) related to obesity:

Overweight, BMI 25-29.9 kg/m2
Obesity, BMI 30+ kg/m2

Using those definitions, approximately 69% of the American adult population is overweight, including 35% who are obese.

The Guideline suggests that a modest reduction in weight of 3-5% in overweight and obese adults may lead to meaningful benefits in terms of triglyceride levels, blood glucose, hemoglobin-A1c, and the risk of developing type 2 diabetes. A greater reduction in weight may lead to meaningful benefits in terms of lowering the blood pressure, improving the LDL and HDL cholesterol levels, reducing the need for medications to control the blood pressure, and further reduce the serum triglyceride and glucose levels.

A diet should be prescribed for overweight and obese individuals, preferably with the assistance of a nutrition professional. A variety of dietary approaches may be suitable, but the successful diet will produce an energy deficit of 500 kcal or more per day. Special caution is advised when an ultra-low calorie diet (<800 kcal/day) is prescribed. No single dietary approach was found to be superior.

In addition to a prescribed diet, overweight and obese individuals will benefit from a “comprehensive lifestyle intervention” that includes physical activity (200-300 min/week), monitoring of the diet and physical activity by a trained “interventionist,” and long-term weight maintenance programs for those who are initially successful with weight loss.

Bariatric surgery is recommended for motivated individuals without successful weight loss using first-line treatments, who have BMI >40 kg/m2 or BMI >35 kg/m2 along with associated obesity-related comorbid conditions. The most appropriate specific type of bariatric surgery will depend upon patient-related factors.

Implications for Athletes

Again, there are no surprises here. This Guideline is very much in keeping with current thinking and practice. For overweight or obese individuals who are beginning a new exercise program, it is encouraging that just 3-5% weight reduction might provide meaningful health benefits. The Guideline makes clear that new exercise programs undertaken in a setting of intentional weight loss should be monitored carefully by a physician.

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Podcast with IMTalk

August 2, 2013 By Larry Creswell, MD Leave a Comment

Earlier this week I had the chance to chat with John Newsom and Bevan Eyles at IMTalk for a segment on an upcoming podcast. Their weekly show originates from Christchurch, NZ and focuses on long-distance triathlon.

When the podcast is available, around August 20th, I’ll put the link here.

We talked about heart health and endurance sport and some of the new information about heart problems that might be caused by too much exercise. We also touched on last year’s report from USA Triathlon about race-related fatalities. Two other recent podcasts in their series contained a segment with Dr. Tamsin Lewis, a doctor and professional triathlete, and a segment with Dr. Douglas Scott, a cardiologist and elite age-grouper. Both segments are devoted to heart issues and are worthwhile listening.