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Dr Larry Creswell

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Laurent Vidal, Elite Triathlete 1984-2015

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The very sad news came this week that retired French elite triathlete, Laurent Vidal, died in his sleep at his home in southern France.

There has been a worldwide outpouring of emotion.  I particularly enjoyed this video.

Life-threatening heart problems are unusual in Olympic-caliber athletes, but Vidal suffered an episode of cardiac arrest at the swimming pool last spring.  I wrote about that episode and his remarkable recovery in a blog post that focused on cardiac arrest, more generally.

After his recovery, Vidal shared very little about his diagnostic evaluation, any conditions that were discovered, and any implications regarding his prognosis.  He immediately retired from the sport of triathlon, though, and I suspect that he was advised that continued participation posed some danger.  He remained physically active over these past months, though, and often shared pictures of himself bicycling or hiking.  Media reports this week mention a pacemaker and I wonder if he actually received an internal cardioverter-defibrillator (ICD) for “secondary prevention” in case of a repeat episode of cardiac arrest.  Unfortunately, even an ICD doesn’t guarantee long-term survival in situations like this.  It’s worth reflecting that Vidal’s first indication of a potential problem was a couple years earlier, when he had an episode of syncope, or fainting.  That’s an important problem to get sorted out.

Vidal’s story surely reminds us that life is sometimes too short.  The remembrances on social media this week speak to the way that Vidal embraced life.  I wish I’d had the chance to meet Vidal.  I’ll always remember his smiling face.

Related Posts:

  1. Laurent Vidal and Cardiac Arrest
  2. Elite Triathles and Heart Problems
  3. Cardiac Screening in Adult Recreational Athletes

Interesting Research Studies from the ACC ’14 Meeting

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This year’s annual meeting of the American College of Cardiology was held in Washington, D.C. last week.  I wasn’t able to attend the meeting, but the results of several studies related to sports cardiology caught my attention.  Here are my Top 8:

1. Prodromal symptoms, exercise, and sudden cardiac arrest (SCA).  In a study reported by Lawless CE et al., questionnaires were distributed to known survivors of SCA.  Prodromal, or warning, symptoms surveyed included chest pain, shortness of breath, and evidence of arrhythmia (syncope, dizziness, palpitations).  Such prodromal symptoms were present in 31% during the month preceding the SCA episode.  Half of the prodromal symptoms occurred at rest and half occurred during exercise.  We’ve known about the importance of recognizing exercise-related arrhythmias, but the important new finding here is the importance of arrhythmic symptoms at rest as a potential warning sign for later SCA.

2. Exercise blood pressure in Olympic athletes.  Little is currently known about blood pressure during exercise for elite athletes.  In a study reported by Caselli S et al., 1,140 Olympic athletes from the 2008 or 2012 Games were divided into 4 groups depending upon their sport:  skill disciplines, power disciplines, mixed disciplines, or endurance disciplines.  These athletes underwent a battery of cardiovascular testing that included measurement of the blood pressure during a maximal bicycle exercise test.  For the entire group, the peak systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 190+/-21 mm Hg and 76 +/- 7 mm Hg, respectively.  Interestingly, there were no differences between athletes of the 4 sporting groups.  A total of 102 athletes had either SBP or DBP above the 95th percentile for the group (220 mmHg and 85 mmHg, respectively).  This new information may allow for better identification of elite caliber athletes with hypertension that should be treated.

3. Maximal heart rate in men and women.  We often use the calculation of 220 minus age to give an estimate of an individual’s maximal heart rate.  This number has bearing in clinical cardiology testing as well as for setting up training zones for endurance athletes.  Based on the observations in more than 25,000 individuals undergoing exercise stress tests, Sydo N. et al. reported that more accurate estimates for individuals older than 40 years may come from these equations:  Men, 216 minus 93% of age; Women, 200 minus 67% of age.  These new equations may provide better estimates for athletes who want to establish appropriate training zones.

4. Cardiovascular health and marathon training.  Zilinski JL et al. reported on a group of 45 male recreational runners who undertook a relatively short 18-week, structured training program leading up to the 2013 Boston Marathon.  Each of the runners had at least one known cardiovascular risk factor at the outset.  They underwent clinical evaluation, echocardiography, VO2max testing, and laboratory evaluation before and again after the training period.  There were significant improvement in:  peak oxygen consumption, body-mass index (BMI), serum triglyceride level, serum low density lipoprotein (LDL) level, serum total cholesterol, and one particular index of ventricular function based on echocardiography.  The results suggest, perhaps not surprisingly, that marathon training may be a useful strategy for improving conventional cardiovascular risk factors.

5. Running and longevity.  A couple recent studies have documented a so-called “U-shaped” relationship between the amount of running and longevity among long-time runners, where individuals with moderate amounts of running enjoyed better longevity compared to those with larger (>20 miles per week) amounts of running.  These previous studies have suggested some sort of “sweet spot” with respect to healthy amounts of exercise.  The reasons and potential mechanisms for this observation remain unclear, though.  In a study reported by Bell AC et al., an update was provided for the ongoing MASTERS Athletic Study, a longitudinal study of runners aged 35 and older.  The investigators tested the hypothesis that perhaps decreased longevity among the highest-volume runners might be due to adverse cardiovascular risk factors (eg, family history of heart disease, high blood pressure, abnormal serum lipid levels, diabetes, smoking) rather than to the amount of running.  It turns out, though, that these factors did not account for the difference in mortality for the 2 groups.  So the reason(s) behind the U-shaped longevity curve (if it’s not due simply to the amount of running) remain unclear.

6. Pre-participation screening.  There have been several guidelines about the utility of pre-participation cardiovascular screening for athletes, including the 4th PreParticipation Physical Evaluation monograph in 2010, the 2007 American Heart Association (AHA) reparticipation screening recommendations, and the Proceedings of the 36th Bethesda Conference in 2005.  In a study reported by Lawless CE et al., 190 Nebraska primary care providers (PCPs) were surveyed about their use of these guidelines in the evaluation of athletes.  The percentage of PCPs who “consistently used” the guidelines were only 7.9%, 11.4%, and 3.2%, respectively.  The percentage of PCPs who were unaware of the guidelines were surprisingly 73.0%, 48.0%, and 76.4%, respectively.  The results suggest that the guidelines are under-utilized and the investigators recognize a potential opportunity for improved screening with better education about the available guidelines.

7. Smartphone apps and silent arrhythmias.  A variety of smartphone apps related to heart rhythm monitoring have become available in recent years.  In a study reported by Sawant AC et al., 103 patients being treated in an outpatient setting used a smartphone app to record their EKG and then also underwent conventional EKG recording in the doctor’s office.  The smartphone app correctly identified atrial fibrillation in almost 90% of cases where the arrhythmia was silent (did not produce symptoms).  This technology will undoubtedly continue to evolve and may enable recording of both silent and symptomatic arrhythmias in the outpatient setting in a much easier and less costly fashion that traditional Holter monitoring.

8. Endurance exercise and cardiac remodeling.  Many different sports qualify for being “endurance” activities, but each has its own unique make-up of so-called dynamic and static exercise components.  In a study reported by Wasfy MM et al., 38 long distance runners were compared to 33 rowers in terms of their cardiac structure and function.  The investigators found that runners had larger left ventricular (LV) volumes but lower LV muscle wall thickness than the rowers.  The function of the LV was similar for the 2 groups.  It’s important to keep in mind that, as far as the heart is concerned, all endurance sports are not created equal!

We can expect more detailed reporting on these studies as they make their way into print form in a scientific journal over the next year or so.  Stay tuned.

Coach John Fox and Aortic Valve Replacement

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NFL Broncos head coach, John Fox, will reportedly undergo aortic valve replacement (AVR) this week.  I’ve gotten some inquiries over the weekend about his situation and I thought I’d take a few minutes to write about aortic valve problems and aortic valve replacement.

This story is reminiscent of Atlanta Falcons coach, Dan Reeves, who had urgent coronary artery bypass surgery in 1998, late in his team’s 14-2 season.  For reference, Reeves made an excellent recovery, rejoined the team just 3 weeks after surgery, and went on to coach for another 5 seasons.

Aortic Valve Disease

The aortic valve is the valve that lets blood out of the heart.  The left ventricle of the heart pumps blood out through this valve into the aorta with each heart beat.  At rest, this might amount to about 5 liters per minute.  The valve ordinarily has 3 tissue thin leaflets, but some individuals are born with just 2, a condition known as bicuspid aortic valve (BAV).

There are 2 different problems with the aortic valve.  The valve can become narrowed or it can leak.  Either situation produces trouble for the heart, which then must do extra work.  When the valve is narrowed, we call the condition aortic stenosis.  When the valve leaks, we call the condition aortic regurgitation.  When there is severe aortic stenosis or regurgitation, aortic valve replacement is often the only available curative treatment.

In this country the most common cause of aortic stenosis in adult patients, by far, is build-up of calcium in the valve leaflets over many years’ time.  This progressive calcification causes the valve leaflets to become thickened.  As a result, they don’t open or close easily and eventually they become immobile.  Severe aortic stenosis most often manifests in patients 60+ years old.  In individuals with BAV, this process occurs much earlier in life, and the condition often manifests in patients in their 40’s and 50’s.  Rheumatic fever is probably the next most common cause.  The normal aortic valve opening is about the size of a half dollar.  But with severe aortic stenosis, the opening can be reduced to the size of a drinking straw.

Aortic regurgitation may occur for a variety of reasons such as:  infection (that we call endocarditis) that destroys the valve leaflets; enlargement of the aorta that stretches the leaflets apart; rheumatic fever; or trauma.

Patients with severe aortic stenosis have symptoms of shortness of breath with exertion, chest pain/discomfort, or light-headedness or blacking out (that we call syncope).  Patients with aortic regurgitation most often have symptoms of shortness of breath with exertion.  Either condition can be revealed by listening to the heart with a stethoscope because either condition produces turbulent blood flow that can be heard as a heart murmur.  The diagnosis is confirmed using ultrasound, in a test known as an echocardiogram.

Once there are symptoms, patients with severe aortic stenosis need operation.  Once the heart function suffers because of aortic regurgitation, operation is needed.  In either case, we usually plan for operation at the earliest, convenient opportunity.  Emergency operations for aortic valve problems are unusual.

In John Fox’s case, we know from reporting that he was in Charlotte, North Carolina to visit his doctor(s) about a known aortic valve problem–one that was being monitored and for which aortic valve replacement was being planned once this year’s football season was complete.  The initial news reports spoke about the possibility of a heart attack, but he apparently became light-headed while playing golf.  It’s not clear if he passed out completely.  He was taken to the hospital where additional testing was completed.  The Broncos then made the announcement that Fox would undergo surgery this coming week.

Aortic Valve Surgery

Aortic valve replacement is a very common heart operation today.  And while there are new technologies that allow for valve replacement in high-risk patients without conventional operation, the vast majority of patients undergo typical open heart surgery to replace the valve.

The patient has general anesthesia with use of a breathing tube to provide ventilation while asleep.  Access to the heart is gained by dividing all or part of the sternum and using a retractor to spread the rib cage open.  The first main part of the operation involves connecting the patient to a heart-lung bypass machine that sits at the side of the operating table and takes over the job of the patient’s own heart and lungs for a period of time.  This allows the patient’s heart to be still and empty of blood.

The next main part involves replacing the valve.  An opening is made in the aorta, the large blood vessel that carries blood away from the heart.  This allows the surgeon to look in and see the diseased valve.  In the most straightforward operation, the patient’s aortic valve is removed using scissors and any calcium-related debris is also removed.  A measuring tool is used to determine the correct size for a substitute valve which is then taken from the shelf.  Sutures are used to sew the substitute valve into the opening left behind where the patient’s valve was removed.  The opening in the aorta is then closed with sutures.

The last major part of the operation involves letting the patient’s own heart and lungs take back over again, and gradually reducing the amount of help that the heart-lung machine provides.  Once the patient’s heart is beating again, the sternum is re-approximated with wires and the overlying tissues and skin are re-approximated using sutures.  The entire operation usually takes about 3 hours.

There are several options for substitute valves.  Mechanical valves are made out of space-age materials and are designed to last forever, but patients must take blood thinning medications to prevent blood clots from forming on the prosthetic valve.  Tissue valves (eg, aortic valve “borrowed” from a pig) don’t require anticoagulants, but the valves don’t last forever.  The modern tissue valves can be expected to last 10-15 years in adult patients and then some will deteriorate; re-replacement of the valve may sometimes be needed.  In special circumstances, other more exotic options may be appropriate, but we won’t consider those options today.

Recovery from Operation

The typical patient wakes up soon after the operation.  The breathing tube and ventilator are withdrawn once the patient is wide awake and breathing on his/her own.  Most patients will spend a night in the intensive care unit and then several more days recovering in a regular hospital room.  A typical stay would be about 5-7 days.  We work hard to have patients up and walking on the first day after operation and most are walking laps around our hospital ward by the time they go home.

Many patients with AVR notice even in just the first couple days after operation that they no longer have the symptoms that led to discovery of their problem.  Particularly for aortic stenosis, the calcification of the valve happens so gradually that patient’s aren’t always aware of how much of a decrement there’s been in their exercise tolerance.

As the sternum heals, we ask that patients avoid physical activities that place stress on the sternum and shoulders (eg, pushing, pulling, reaching, etc.) for 1 month after the operation.  The sternum regains about 75% of its strength in about 1 month.  In my practice we also restrict driving for that same month.  Most any other activity is allowed and we encourage lots of walking as the preferred type of exercise.

Each patient’s situation with return-to-work is different, not only because each patient’s recovery is different but also because each patient’s job situation is different.  In Fox’s case, if all goes well, I wouldn’t be surprised to see him back at work, at least in some capacity, very quickly.

Best wishes to John Fox!

George W. Bush Gets a Stent

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We learned from news reports earlier this month that former President George W. Bush was treated with a coronary stent for a blockage in a coronary artery that was discovered during his annual medical check-up.  Of course, a great many Americans are treated each day for coronary artery disease (CAD), but Bush’s case draws my attention not only because he’s the former President but also because he’s known to be physically active, especially with cycling.


Bush’s Medical History

The fine details of Bush’s most recent health matters haven’t been made public, and might never be.  But we know that while President from 2001 to 2009 he enjoyed comprehensive medical check-ups performed at the Bethesda Naval Medical Center.  Each year, short statements were issued by the White House that summarized the President’s health.  We can take a look back at some of that reporting.

Before taking office, the President received annual medical check-ups from Dr. Kenneth Cooper at the Cooper Clinic in Dallas, Texas.  We know that, at the time he took office in 2009, he had no heart problems and no significant family history of heart disease.  He occasionally smoked a cigar, did not drink alcohol, and had typical caffeine intake in the form of diet soft drinks and coffee.

From his examination at age 58 in 2004, we know that:  he was 6 feet tall, weighing 200 pounds; his body fat was 18.25%; his resting heart rate was 52 and the blood pressure was 110/60; and the total serum cholesterol level was 170 mg/dL, with a decrease in the LDL (bad cholesterol) and increase in the HDL (good cholesterol) from one year previously.  He was noted to have mild calcification of the coronary arteries (presumably based on a screening cardiac CT scan) and both aspirin and a cholesterol-lowering agent were prescribed.  At the time, he was running 7 1/2 minute miles on the treadmill and was cycling several times per week.

In 2005 we learned that the President’s weight had decreased by a few pounds and the blood pressure and resting heart rate remained low.  He underwent an exercise treadmill test that was normal and his doctors concluded that he was at “very low risk of coronary artery disease.”  By 2005 Bush had given up running because of difficulties with knee pain, but continued to be active with cycling and weightlifting.

In 2006 at age 60 he was noted to have an EKG without worrisome abnormalities and a normal stress echocardiogram.  Doppler ultrasound studies of the arterial blood supply to the legs was normal and a screening ultrasound of the abdomen showed no evidence of abdominal aortic aneurysm.  Laboratory values included:  total cholesterol 174 mg/dL, HDL 60 mg/dL, LDL 101 mg/dL, triglycerides 61 mg/dL, and normal values for C-reactive protein (CRP) and homocysteine.  Interestingly, it was reported that he was taking no prescription medications despite the 2004 statement about the recommendation for a cholesterol-lowering agent.  On the basis of the available information, the President was thought to have “low” to “very low” coronary artery disease risk.

The Coronary Stent

As we all know, Bush left office in 2009.  Since then, his medical affairs have been private.  So, fast forward to 2013….

We know that Bush went recently for his annual medical check-up at the Cooper Clinic and the following day at Texas Health Presbyterian Hospital was treated with a coronary stent for a blockage in a coronary artery that had been discovered duringn his evaluation.  The details have not been made public, but it’s probably fair to assume that he underwent a stress test that was abnormal and that coronary arteriography was organized for the following day, with implantation of the coronary stent at the same setting.

The fact that Bush was treated with a stent for the coronary artery blockage has created a bit of a stir in the medical community.  For those who are interested you can read more at:

“Did George W. Bush really need a stent?,” an article by Larry Huston in Forbes.

“The George W. Bush stent case:  An incredible teaching opportunity on the basics of heart disease,” a blog piece by Dr. John Mandrola.

“Heart stents still overused, experts say,” an article by Anahad O’Connor at NY Times Well.

Basically, the controversy revolves around the appropriate treatment for asymptomatic patients–those without chest pain, heart attack, etc.–or those with so-called “stable” symptoms–for instance, chest pain with exertion–who are found to have blockage(s) in the coronary arteries.  In truth, there has been no public reporting on whether or not Bush had any such symptoms, either with exertion or at rest.  And there has been no updated reporting on Bush’s physical activity level or other relevant risk factors for CAD.  But information from the best scientific studies suggests that asymptomatic patients and those with “stable” CAD fare no better, with respect to heart attack, stroke, or death, with a stent than without, so long as the best possible medical therapy is provided.

At any rate, this controversy will be one for our community of heart professionals to discuss and sort out.

What Can We Learn?

From the athlete’s perspective, though, Bush’s story reminds us of the importance of coronary artery disease as we age, even if we remain physically active.  A few thoughts….

1.  The discovery of CAD is almost always a surprise….particularly for an athlete.  Nobody is immune from this disease, even if remaining physically active helps guard against it.

2.  There is a set of well-established risk factors for CAD.  I’ve talked about this issue previously here at the blog.  Let’s remember that there are some risk factors that, unfortunately, can’t be modified:  increasing age, being male, and having a family history of early CAD.  Other risk factors are under our control:  obesity, high blood pressure, smoking, abnormal serum cholesterol and lipid levels, diabetes, and physical inactivity.  Adult athletes should know where they stand with respect to these risk factors and work to improve any that can be modified favorably.  An ongoing relationship with a healthcare provider will offer the necessary framework for this.  Periodic measurement of the blood pressure and testing of the serum cholesterol/lipid levels every 5 years are recommended.

3.  Our personal situation with CAD will likely change over time.  The process in which plaque builds up in the coronary arteries can begin early in our lives.  But this process is often progressive as we age.  That’s why we say that increasing age is a risk factor.  Bush’s story illustrates just how this can happen.  In 2004-2006 he had very favorable clinical and laboratory data regarding his risk of CAD, including a normal stress echocardiogram in 2006.  Yet today we know that an important blockage had formed, or more likely progressed, in the interim.  It’s important, then, to periodically re-visit our circumstance with CAD.

4.  Warning signs are important.  Important blockages in the coronary arteries often lead to symptoms of angina–chest pain/discomfort or perhaps difficulties with breathing.  When angina occurs with exertion, we call it exertional or stable angina.  When angina occurs at rest, we call it unstable or rest angina.  Either form of angina should prompt timely evaluation.  That evaluation may take the form of stress testing or coronary arteriography to look for blockages in the coronary arteries.  Unfortunately, there are some patients whose first sign of trouble is a heart attack, or myocardial infarction.  This can occur in athletes and non-athletes, alike.

Related Posts:
1.  Coronary Artery Disease:  The Essentials
2.  Two Stories, Two Endings, a blog post about endurance athletes and CAD.
3.  In the News:  Coronary Plaque Build-up in Marathoners