heart disease

Book Review: Cardiac Athletes

July 6, 2014 By Larry Creswell, MD 3 Comments

Hot off the press is a new book by Lars Andrews, entitled simply, Cardiac Athletes. I had a chance to read the book over the July 4th holiday weekend and I thought I’d share some details here at the blog. I enjoyed the book and recommend it highly.

Lars Andrews is the founder of Cardiac Athletes, the worldwide support community for athletes with heart disease. I’ve written previously here at the blog about the organization’s many activities. You can find them online at their website and also on Facebook. If you’re an athlete with heart disease, you’ll find an active online forum that helps athlete patients make useful connections with others in similar circumstances. On the charitable front, the organization raises money to support donation of automatic external defibrillators (AEDs) to communities in need and to support cardiac screening programs for athletes.

This new book will be good reading for a variety of folks–athletes, of course, with heart disease; healthcare workers who care for these athlete patients; and pretty much anybody who enjoys reading inspirational personal stories from athletes.

Andrew LaGerche, MBBS, PhD, a physician-scientist, himself a talented endurance athlete, and with a long professional interest in athletes and heart disease, writes a great Foreword. In the Preface, Andrews details the history and evolution of the Cardiac Athletes organization and sets the stage for the remainder of the book. The Introduction features his take on 10 repeating themes that will be found in the athlete stories: cardiac athletes are pioneers; we need sports cardiology centres; are we starting to see a post athletic epidemic?; would preschool screening be bad?, among others.

The bulk of the book is a collection of the personal stories from 17 athletes affected by heart disease. Each athlete shares his/her journey from the discovery of their problem, through its diagnosis and treatment, and the long-term consequences. In many cases, there are illustrations which bring clarity to the specific heart problem being described. This is very helpful to non-medical readers who won’t be familiar with the details. Each chapter is a rare, honest look at how these athletes approach sport in the context of heart disease. These stories are just very real.

At the end is a useful glossary of terms that will make the book more accessible and also a useful reference, or reading list.

The book is currently available in print form for $14.98 from Create Space. Proceeds from the book will go to the Cardiac Athletes Trust Fund to support the organization’s charitable activities.

Sergei M. Grinkov, Figure Skater, 1967 – 1995

September 29, 2013 By Larry Creswell, MD 1 Comment

At the time of his death at age 28 in 1995, Russian Sergei Grinkov was at the top of his career in figure skating. He and his wife, Ekaterina Gordeeva, had won four world doubles figure skating championships and were the Olympic champions in 1988 and 1994.

While skating during a practice session in Lake Placid on November 20, 1995, Grinkov became light-headed, slumped to the ice, and then lost consciousness. His coach recognized the urgency of the situation and provided CPR almost immediately. EMS personnel arrived within minutes and inserted a breathing tube. But despite their efforts for more than an hour, Grinkov never regained a heartbeat and died later at the Adirondack Medical Center.

An autopsy showed extensive coronary artery disease (CAD), with nearly occlusive blockages affecting two of the three main coronary arteries. Moreover, there was significant enlargement of the heart. The pathologist concluded that Grinkov had suffered from an acute myocardial infarction, seemingly unrecognized, sometime during the 24 hours preceding his death and then suffered a fatal arrhythmia at the ice rink.

Grinkov’s death was obviously unexpected. In retrospect, it was learned that Grinkov had long-standing, untreated high blood pressure, with typical diastolic blood pressure measurements of more than 110 mm Hg. This was thought to contribute to the marked enlargement of his heart. According to reports, though, the high blood pressure measurements had often been attributed simply to “nerves.”

It also turns out that Grinkov’s father, Mikhail Grinkov, died at age 52 after his fourth heart attack. But like Sergei, his father had none of the typical risk factors for CAD. These unusual facts caught the attention of Johns Hopkins cardiologist, Pascal Goldschmidt, MD, who was able to study a sample of Grinkov’s blood and find through DNA analysis that he carried a variant of a platelet antigen gene that we now know as PLA-2 or the Grinkov factor. That variant, present in about 20% of the general population, is now known to be associated with both heart attack and stroke at an earlier age than the general population.

Elite Triathletes and Heart Problems

February 17, 2013 By Larry Creswell, MD 35 Comments

A bunch of recent and contemporary elite triathletes have had problems with heart disease. I thought I’d gather some of their stories here….and I’ll try to add to the list over time. Please post a comment to let me know who to add. The collection of stories shows the variety of heart problems that confront endurance athletes and certainly makes the point that fitness does not always equate with heart health.

I haven’t met any of these athletes, and outside of a few emails and Twitter conversations with a couple, I know their stories only from what’s been reported in the popular press or shared at the athletes’ blogs or websites. So I’ll apologize in advance if I have any of the details confused….and be prepared to set the record straight, if need be. I’ve done my best!

Steve Larsen was a former American professional road cyclist, a teammate of Lance Armstrong on the Motorola cycling team, who also enjoyed successful careers with mountain biking, track cycling, and cyclocross before turning to triathlon. Larsen’s career is well chronicled in an article at Slowtwitch. He collapsed with sudden cardiac death during a track running workout in Bend, Oregon on May 29, 2009 at age 39 and is survived by his wife and five young children. An autopsy showed severe coronary artery disease (CAD), blockages in the coronary arteries that are the typical cause of myocardial infarction, or “heart attack.” Dr. Alex McDonald offers a nice article about CAD and its implications at xtri.com. I’ll also share a link to a website with a collection of photographs and kind rememberances about Larsen.

Torbjorn Sindballe was a Danish professional triathlete whose career highlights include wins at the 2000 and 2006 ITU long course world championships and a 3rd place finish at the 2007 Ironman World Championship (pictured above). Starting in 2005 he was bothered by intermittent chest pains and underwent evaluation that showed he had a bicuspid aortic valve (BAV). I’ve written about this condition here at the blog. At the time of his diagnosis, his aorta had a normal diameter and there was no problem with the aortic valve. He continued to compete, with occasional re-evaluation. On June 30, 2009 he announced his retirement from triathlon, citing concerns about enlargement of the aorta or damage to the aortic valve with continued participation. There is a great Q&A with Sindballe in an article at Slowtwitch where he is very candid about his heart problem. Sindballe now exercises recreationally and is a member of Ironheart Racing Team, a Seattle-based team of multisport athletes from all over the country (and world) with various heart problems.

Normann Stadler is a retired German professional triathlete whose career highlights included wins at the 2004 and 2006 Ironman World Championships. More recently, as shown in the picture, he was a member of the Commerzbank Triathlon Team. In the summer of 2011 he was bothered by chest seemingly mild breathing difficulties and an unexplained fall-off in performance and sought evaluation. He was found to have bicuspid aortic valve (BAV), severe aortic valve regurgitation (leaking), and a very large (7 cm) aortic aneurysm of the ascending aorta. He underwent urgent surgery on July 4, 2011 for repair of his aortic valve and replacement of the beginning portion of the aorta. I’ve written here at the blog about athletes and BAV and shared some thoughts in an article at Endurance Corner about the surprising turn of events for Stadler. Stadler gives a great interview with Bob Babbitt, sharing his thoughts about his heart troubles. It’s a remarkable story.

Samantha Warriner is a professional triathlete from New Zealand whose career includes an overall ITU World Cup series win. She recalls problems with irregular rapid heart beat as a child, but no specific diagnosis was made back then. This arrhythmia problem became worse as her career progressed in triathlon and was particularly bothersome in the 2010 season and especially during the run portions of 70.3 races. She can recall episodes where her heart rate would be as high as 230 beats per minute. With careful evaluation, she was found to have a supraventricular tachycardia (SVT)–ana rhythmia that involves the upper chambers (atria) of the heart–and underwent a successful ablation procedure for this arrhythmia at age 39 on December 1, 2010. She made a quick recovery and went on to be the winner at the Ironman New Zealand race in March, 2011, just 3 months later. You can read an interesting Q&A with Warriner in an article at Slowtwitch.

Erin Densham is a professional triathlete from Australia whose career already includes an U23 world championship in 2006, a 22^ndplace finish in the Olympics in 2008, and a bronze medal most recently at the 2012 London Olympics. Thinking back, she can recall troubles with a “racing heart” early in her childhood. Her difficulties with an arrhythmia were very evident when she had to be rescued from the water at the 2009 Hy-Vee Triathlon in Des Moines, Iowa. She was found to have a supraventricular tachycardia (SVT) and underwent a successful ablation procedure after in December, 2009. Since then, she reports that she’s had no problems with recurrent arrhythmias. You can read more about Densham’s story in an article at Inside Triathlon.

Gina Ferguson (Crawford) is a professional triathlete from New Zealand with multiple Ironman victories to her credit. Her heart troubles came to light after she fainted after the bike portion of the 2009 Challenge Roth triathlon and was unable to finish the race. Ferguson shares the tale at her blog. She was found to have bicuspid aortic valve (BAV), a congenital condition where the aortic valve has 2, rather than the normal 3 cusps. I’ve written about this condition here at the blog. She presumably has no significant narrowing (stenosis) or leakage (regurgitation) of the valve and no enlargement of the nearby aorta. She continues to train and compete, with periodic monitoring of her condition.

Justin Park is an American professional triathlete whose heart problems date to his high school days. He had several episodes of fainting, or syncope, and was found to have congenital long QT syndrome (LQTS). I’ve written about this condition here at the blog. Individuals with LQTS are predisposed to have episodes of syncope or even sudden cardiac death, so Park received a recommendation that he not continue to participate in sports. A number of years later, his physicians determined that his risk for these problems was not high and he took up triathlon. Interestingly, he has also had difficulty with at least one episode of atrial fibrillation in 2010 that may have been due to underlying thyroid disease. He writes about these issues at his blog.

Greg Welch is a retired Australian professional triathlete with a storied career at all distances of triathlon. His victories include the 1990 ITU World Championship, 1993 World Duathlon Championship, 1994 Long Course World Championship, and 1994 Ironman World Championship. His first problems with heart disease manifested during the swim portion of the 1999 Ironman World Champship. He had trouble with breathing that he described as asthma-like. He continued on in the race, had multiple episodes of near-syncope (blacking out), and struggled to an 11^th place finish–a remarkable feat. He would go on to compete a week later at the Xterra World Championship before seeking complete evaluation. He was found to have ventricular tachycardia (VT). He’s had a number of heart procedures, including implantation of an internal cardioverter-defibrillator (ICD) that can provide a life-saving shock should the arrhythmia recur.

Chris Legh is an Australian professional triathlete who has enjoyed considerable success over many years in long course triathlon, with 2 Ironman wins and many 70.3 wins to his credit. He is also a 6-time Australian champion in Xterra. Starting in 2003 he had difficulties with breathing during the later stages of races that prompted evaluation that disclosed a patent foramen ovale (PFO), a type of atrial septal defect (ASD)–a (usually) small hole in the heart between the left and right atrium. In his case, there must have been enough blood flow through that opening to cause fluid build-up in the lungs and difficulty breathing. I’ve written here at the blog about athletes and ASD. In a Q&A with Slowtwitch, Legh talks about this condition and other health problems he’s dealt with in recent years.

Emma Carney is a retired Australian professional triathlete and one of the greatest Australian triathletes in history. She claims 19 ITU World Cup wins and ITU World Championship titles in 1994 and 1997. She retired from competition in 2004 after suffering a sudden cardiac arrest from which she was successfully resuscitated. Her arrhythmia was ventricular tachycardia (VT) and she underwent implantation of an internal cardioverter-defibrillator (ICD) that same year. Although she was advised not to continue in sports, for fear of recurrent arrhythmias that might cause loss of consciousness as well as a shock from the ICD, she continues to train and compete in various endurance and multisport events. I’ve written here at the blog about a unique registry at the Yale University School of Medicine, where athletes with an ICD who choose to exercise/train/compete are followed longitudinally in an effort to quantify the actual–not just predicted–risks to the athletes.

Amanda Lovato is an American professional triathlete who focuses on long course triathlon. She recalls being bothered as early as 2003 with abnormally high heart rates, seemingly without explanation, during both training and competition. Her condition was recently diagnoses as a supraventricular tachycardia (SVT) and she underwent a successful ablation procedure in November, 2012. At her blog, Lovato writes about the troubles leaading up to her diagnosis and shares her experience with the ablation experience and returning to training.

Cardiac Arrest? Heart Attack? Heart Failure?

April 11, 2012 By Larry Creswell, MD Leave a Comment

I’ve heard from a bunch of readers that our terms cardiac arrest, heart attack, and heart failure are confusing.

Today I thought I’d offer a quick vocabulary lesson. One of the biggest challenges for students of medical school and other health professions schools is learning the 1,000’s of words that medical professionals use, but we end up with words and phrases that are very specific and very descriptive.

Cardiac Arrest. This is an electrical problem of the heart. The electrical activity of the heart stops or becomes disorganized in what we call an arrhythmia. And because of the electrical problem, the heart stops pumping blood. If you’ve attended CPR class, you’ll know that the electrical problems include PEA (pulseless electrical activity), ventricular tachycardia (VT), ventribular fibrillation (VF), and asystole.

When athletes collapse during training or competition, cardiac arrest is usually the problem.

Heart Attack. This is a plumbing problem in the heart. Heart attack is the lay term for the medical problem we call myocardial infarction, or MI. This problem is due to blockages in the coronary arteries–the small arteries that bring bloodflow and oxygen to the heart muscle itself.

In the most common scenario, there is build-up of cholesterol or lipid-laden plaque in the wall of a coronary artery that produces narrowing of the artery and reduced bloodflow in that artery. When that bloodflow is sufficiently reduced, individuals experience chest pain that we call angina. When the angina occurs with exertion, we call it exertional angina. When the angina occurs at rest, we call it unstable angina or rest angina.

Myocardial infarction occurs when one of these plaques ruptures (on the inside of the coronary artery), exposing the plaque material to the bloodstream. The body responds by forming a blood clot at that location, further restricting–and possibly stopping–bloodflow in that artery. With no bloodflow or oxygen, the heart muscle in the area of that artery dies pretty quickly. When heart muscle dies, the process can be detected on the EKG and by the presence of heart enzymes (released into the bloodstream from dying heart muscle cells) on a blood test.

Heart Failure. We use this term when the heart pumping function is weak. This can be either an acute, or short-lived problem, or a chronic, long-term problem. There are many causes, including myocardial infarction, but also including various problems with the heart valves, inherited conditions, and others.

A Useful Video Clip. One of my colleagues at work brought to my attention a great video clip on the topic of Heart Disease and Heart Attacks at The Khan Academy. With the help of some great illustrations at the blackboard, the narrator goes over each of these problems. Take a look.

Cardiacathletes.com: An Online Patient Support Community

December 20, 2011 By Larry Creswell, MD 2 Comments

I’ve been aware of an online patient support community called Cardiac Athletes for a while now. I got an email yesterday from Lars Andrews, their chief cardiac physiologist asking if I’d spread the word about their site.

Taking a look, the site brings together athletes from around the world with various heart conditions. There is some general information that will be useful to athlete patients, but the biggest opportunity here is the Forum, where athletes can connect with each other about their medical conditions.

So check out www.cardiacathletes.com.