Replies to This Discussion

Permalink Reply by P. Venkatraman on September 26, 2009 at 10:01

Hello Ans,

I am a CABG patient who runs HMs annually but trains throughout the year.

I am not sure of the issue and its possible solutions, but you might consider posting this at cardiacathletes.co.uk which is a forum for all cardiac patients who are still athletic...or athletes who encounter cardiac issues :-)

Venkat

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Permalink Reply by ans on September 26, 2009 at 12:54

Thanks Venkat for the suggestion. I will do so.

P. Venkatraman said:

Hello Ans,

I am a CABG patient who runs HMs annually but trains throughout the year.

I am not sure of the issue and its possible solutions, but you might consider posting this at cardiacathletes.co.uk which is a forum for all cardiac patients who are still athletic...or athletes who encounter cardiac issues :-)

Venkat

• ▶ Reply

Permalink Reply by Srinivasa SA on March 12, 2010 at 13:02

Hi, This is little old thread, but still I am interested to know the diagnosis of this issue.
Did you get more clarity on this?

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Permalink Reply by zico on March 12, 2010 at 13:35

Ans,
You haven't stated the recommendations of your cardiologist and whether they feel alarmed with your ECG.

I am not a doctor but can only ask you to make a self-assessment of "state of well-being". You must ensure that you feel energetic, that you have a good apetite and that you sleep enough to feel refreshed. If this is in place, do continue to run. It is only when adaptation to increasing mileage and racing stress, does not take place, combined with other psychological stressors, that you could possibly put your heart at risk.

Having said that, I must share that subnormal resting pulse rate is a "relative" indicator compared to the normal population. The doc compares your RPR with the Joneses next door and not with athletes - which you are:-) It is found that when RPR goes below 50 bpm, the term being used is Sinus-Bradycardia and while it sounds ominous, it is actually cause for rejoicing, because you are now stressing your heart a lot less than earlier - it beats only 50 times compared to the 70 times per min, it used to when you were sedentary but still - healthy. As a marathoner, it is not unusual to have a RPR < 50 - how much is it btw?:-)

For other parameters, you should share with your cardiologist that you are a distance runner because I suspect that one of the parameters you stated as abnormal, could be due to cardiac muscle hypertrophy - which is normal, because as a distance runner your cardiac muscle is supposed to grow strong. BUT - as I stated, I'm not a doc.

When in doubt, go to the expert and don't stop until you get an "all clear".
safe running
zico

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Permalink Reply by Rohit on March 12, 2010 at 16:09

This video doesn't entirely answer your questions, but I think it covers few of the concerns: http://vimeo.com/6188975

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Permalink Reply by ans on March 13, 2010 at 20:16

Thanks Zico.
As you had indicated, the cardiologists also felt that distance running can explain my 'sinus bradicardia' (45bpm. Why do I always read it as baccardi?) but were confused by its combination with the other parameters. Thankfully they did not find it 'alarming' and have given me the green signal to continue running but to stop and consult them immediately if there are any other symptoms like breathlessness, chest pain etc. They also felt that while stopping running could certainly get my ECG readings to 'normal' range, I could lose the control over my cholestrol levels that running has achieved - one of the reasons why I started regular running in the first place.
So, I continue to run, though I have cut down the intensity somewhat. I run to rest, relax and help me to deal better with the fair share of issues that life has thrown up at me and certainly not to add to it. I run only when I feel the spring in my strides and it doesnt happen without rest and recovery from previous efforts.

zico said:

Ans,
You haven't stated the recommendations of your cardiologist and whether they feel alarmed with your ECG.

I am not a doctor but can only ask you to make a self-assessment of "state of well-being". You must ensure that you feel energetic, that you have a good apetite and that you sleep enough to feel refreshed. If this is in place, do continue to run. It is only when adaptation to increasing mileage and racing stress, does not take place, combined with other psychological stressors, that you could possibly put your heart at risk.

Having said that, I must share that subnormal resting pulse rate is a "relative" indicator compared to the normal population. The doc compares your RPR with the Joneses next door and not with athletes - which you are:-) It is found that when RPR goes below 50 bpm, the term being used is Sinus-Bradycardia and while it sounds ominous, it is actually cause for rejoicing, because you are now stressing your heart a lot less than earlier - it beats only 50 times compared to the 70 times per min, it used to when you were sedentary but still - healthy. As a marathoner, it is not unusual to have a RPR < 50 - how much is it btw?:-)

For other parameters, you should share with your cardiologist that you are a distance runner because I suspect that one of the parameters you stated as abnormal, could be due to cardiac muscle hypertrophy - which is normal, because as a distance runner your cardiac muscle is supposed to grow strong. BUT - as I stated, I'm not a doc.

When in doubt, go to the expert and don't stop until you get an "all clear".
safe running
zico

• ▶ Reply

Permalink Reply by ans on March 13, 2010 at 20:25

Hi Srinivasa,
Things haven't become clear. However thankfully it hasn't become worse and I continue to run, with the permission of my cardiologist.

Srinivasa SA said:

Hi, This is little old thread, but still I am interested to know the diagnosis of this issue.
Did you get more clarity on this?

• ▶ Reply

Permalink Reply by Hrishikesh Kumar on March 22, 2010 at 21:00

First of all- Cardiac hypertrophy (Increased thickness of heart musculature of heart) can happen with endurance sports. This hypertrophy is physiological and quite different from the pathological hypertrophy which can be seen in hypertrophic cardiomyopathy.

Hypertophic cardiomyopathy (HCM) is a condition where you have a large heart, right from birth and thickness is quite substantial just below a valve (aortic valve) through which pure blood is ejected out of the heart. This is a rare condition but usually it remains unrecognized. If your ECG was normal previously, rest assured - you dont have HCM as this is a congenital condition.Some of the marathon deaths have been attributed to pre-existing unrecognized HCM. In marathon you need to eject huge amount of blood out and if someone has HCM, the thickness below aortic valve prevent that output and hence complications.

Now, ECG is electrical record of heart activities from surface. The electrical conduction is happening in a wire system in inner layer of heart. If the heart muscles have hypertrophied because of endurance sport, you have a wall of thick muscles between the conduting wire system and surface electrodes. The shape of heart muscle is not the same as it was before. Understandbly that will change the orientation of electrical conduction in reference to surface electrode and hence change the axis.

Now think of adaptation of heart as a pump- In endurance sport, it has to pump blood more efficiently. For that it has to stay in diastole (blood receiving phase) longer. You can use a large Holi pichkari (those metal pichkari with piston) only when you suck the colour slowly upto its brim. So the frequency of sucking colour and then ejecting per minute becomes slower but more efficient. That analogy works with resting heart rate. And thats why low heart rate. One beat of heart on ECG is documented by P, QRS and T waves. The distance between this waves are seen in ECG as (PR interval, QT interval etc). If your heart rate is slow and one beat sustains longer, obviously the distance between individual waves will be longer. Hence prolonged P-R interval (which is known as 1st degree AV block), or increased Q-T interval. So any athlete having physiological bradycardia (sinus bradycardia, low resting heart rate) will have these intervals prolonged.

If the above blurb does not make sense, read 3-4 times (thats the way in medical science). If it still does not make sense- then take home message is - all the changes you mentioned are physiological and they are normal adaptations. Dont worry about them and keep running.

On the other hand, if your ECG shows second or third degree heart block or something known as LBBB (left bundle branch block), then dont ignore them.



Best

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Permalink Reply by Chandramohan H on March 29, 2010 at 20:18

Hi,

I thought this is the right group to share this information which i received as an email today. I beleive many of us overlook the imporatance of proper sleep.

About 5-6 months ago, many of us heard about the sad demise of Ranjan Das from Bandra, Mumbai. Ranjan, just 42 years of age, was the CEO of SAP-Indian Subcontinent, the youngest CEO of an MNC in India . He was very active in sports, was a fitness freak and a marathon runner. It was common to see him run on Bandra's Carter Road . Just after Diwali, on 21st Oct, he returned home from his gym after a workout, collapsed with a massive heart attack and died. He is survived by his wife and two very young kids.

It was certainly a wake-up call for corporate India . However, it was even more disastrous for runners amongst us. Since Ranjan was an avid marathoner ( in Feb 09, he ran Chennai Marathon at the same time some of us were running Pondicherry Marathon 180 km away ), the question came as to why an exceptionally active, athletic person succumb to heart attack at 42 years of age.

Was it the stress?

While Ranjan had mentioned that he faced a lot of stress, that is a common element in most of our lives. We used to think that by being fit, one can conquer the bad effects of stress. So I doubted if the cause was stress.

The Real Reason

However, everyone missed out a small line in the reports that Ranjan used to make do with 4-5 hours of sleep. This is an earlier interview of Ranjan on NDTV in the program 'Boss' Day Out': Boss' Day Out: Ranjan Das of SAP India.

Here he himself admits that he would love to get more sleep ( and that he was not proud of his ability to manage without sleep, contrary to what others extolled ).

The Evidence

Last week, I was working with a well-known cardiologist on the subject of ‘Heart Disease caused by Lack of Sleep’. While I cannot share the video nor the slides because of confidentiality reasons, I have distilled the key points below in the hope it will save some of our lives.

Some Excerpts:

· Short sleep duration ( <5 or 5-6 hours ) increased risk for high BP by 350% to 500% compared to those who slept longer than 6 hours per night. Paper published in 2009. As you know, high BP kills.

· Young people ( 25-49 years of age ) are twice as likely to get high BP if they sleep less. Paper published in 2006.

· Individuals who slept less than 5 hours a night had a 3-fold increased risk of heart attacks. Paper published in 1999.

· Complete and partial lack of sleep increased the blood concentrations of High sensitivity C-Reactive Protein (hs-cRP), the strongest predictor of heart attacks. Even after getting adequate sleep later, the levels stayed high!!

· Just one night of sleep loss increases very toxic substances in body such as Interleukin-6 (IL-6), Tumour Necrosis Factor-Alpha (TNF-alpha) and C-reactive protein (cRP). They increase risks of many medical conditions, including cancer, arthritis and heart disease. Paper published in 2004.

· Sleeping for <=5 hours per night leads to 39% increase in heart disease. Sleeping for <=6 hours per night leads to 18% increase in heart disease. Paper published in 2006.

Ideal Sleep

For lack of space, I cannot explain here the ideal sleep architecture. But in brief, sleep is composed of two stages: REM ( Rapid Eye Movement ) and non-REM. The former helps in mental consolidation while the latter helps in physical repair and rebuilding. During the night, you alternate between REM and non-REM stages 4-5 times.

The earlier part of sleep is mostly non-REM. During that period, your pituitary gland releases growth hormones that repair your body. The latter part of sleep is more and more REM type.

For you to be mentally alert during the day, the latter part of sleep is more important. No wonder when you wake up with an alarm clock after 5-6 hours of sleep, you are mentally irritable throughout the day (lack of REM sleep). And if you have slept for less than 5 hours, your body is in a complete physical mess ( lack of non-REM sleep ), you are tired throughout the day, moving like a zombie and your immunity is way down ( I’ve been there, done that ).

Finally, as long-distance runners, you need an hour of extra sleep to repair the running related damage.



In conclusion:

Barring stress control, Ranjan Das did everything right: eating proper food, exercising ( marathoning! ), maintaining proper weight. But he missed getting proper and adequate sleep, minimum 7 hours. In my opinion, that killed him.
If you are not getting enough sleep ( 7 hours ), you are playing with fire, even if you have low stress.

I always took pride in my ability to work 50 hours at a stretch whenever the situation warranted. But I was so spooked after seeing the scientific evidence last week that since Saturday night, I ensure I do not even set the alarm clock under 7 hours. Now, that is a nice excuse to get some more sleep.

Unfortunately, Ranjan Das is not alone when it comes to missing sleep. Many of us are doing exactly the same, perhaps out of ignorance

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Permalink Reply by ashok on March 29, 2010 at 21:12

true, started taking note of this fact and making it a point to get proper sleep more often .... the red dragon gang misses me now :)

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Permalink Reply by ans on March 30, 2010 at 20:22

That's about the best explanation I ever got - including all the docs I consulted.
Thanks a ton.
ans

Hrishikesh Kumar said:

First of all- Cardiac hypertrophy (Increased thickness of heart musculature of heart) can happen with endurance sports. This hypertrophy is physiological and quite different from the pathological hypertrophy which can be seen in hypertrophic cardiomyopathy.

Hypertophic cardiomyopathy (HCM) is a condition where you have a large heart, right from birth and thickness is quite substantial just below a valve (aortic valve) through which pure blood is ejected out of the heart. This is a rare condition but usually it remains unrecognized. If your ECG was normal previously, rest assured - you dont have HCM as this is a congenital condition.Some of the marathon deaths have been attributed to pre-existing unrecognized HCM. In marathon you need to eject huge amount of blood out and if someone has HCM, the thickness below aortic valve prevent that output and hence complications.

Now, ECG is electrical record of heart activities from surface. The electrical conduction is happening in a wire system in inner layer of heart. If the heart muscles have hypertrophied because of endurance sport, you have a wall of thick muscles between the conduting wire system and surface electrodes. The shape of heart muscle is not the same as it was before. Understandbly that will change the orientation of electrical conduction in reference to surface electrode and hence change the axis.

Now think of adaptation of heart as a pump- In endurance sport, it has to pump blood more efficiently. For that it has to stay in diastole (blood receiving phase) longer. You can use a large Holi pichkari (those metal pichkari with piston) only when you suck the colour slowly upto its brim. So the frequency of sucking colour and then ejecting per minute becomes slower but more efficient. That analogy works with resting heart rate. And thats why low heart rate. One beat of heart on ECG is documented by P, QRS and T waves. The distance between this waves are seen in ECG as (PR interval, QT interval etc). If your heart rate is slow and one beat sustains longer, obviously the distance between individual waves will be longer. Hence prolonged P-R interval (which is known as 1st degree AV block), or increased Q-T interval. So any athlete having physiological bradycardia (sinus bradycardia, low resting heart rate) will have these intervals prolonged.

If the above blurb does not make sense, read 3-4 times (thats the way in medical science). If it still does not make sense- then take home message is - all the changes you mentioned are physiological and they are normal adaptations. Dont worry about them and keep running.

On the other hand, if your ECG shows second or third degree heart block or something known as LBBB (left bundle branch block), then dont ignore them.



Best

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Permalink Reply by Hrishikesh Kumar on March 31, 2010 at 18:09

You are welcome, ANS. A disclaimer here- I am a neurologist and not a cardiologist. There are lot of finer and subtle facts which I have not written in my previous post. I'll like to know about your exact QTc interval (not QT but QTc, that is QT interval corrected for the heart rate). If you are really interested, you can read following reference- full text is free on web.
Br J Sports Med 2009 43: 669-676

But bottomline is - dont worry and keep on running. If you are still anxious, you can use heart rate monitor while running and try to stay below 80% of your maximum heart rate.

Best

ans said:

That's about the best explanation I ever got - including all the docs I consulted.
Thanks a ton.
ans

Hrishikesh Kumar said:

First of all- Cardiac hypertrophy (Increased thickness of heart musculature of heart) can happen with endurance sports. This hypertrophy is physiological and quite different from the pathological hypertrophy which can be seen in hypertrophic cardiomyopathy.

Hypertophic cardiomyopathy (HCM) is a condition where you have a large heart, right from birth and thickness is quite substantial just below a valve (aortic valve) through which pure blood is ejected out of the heart. This is a rare condition but usually it remains unrecognized. If your ECG was normal previously, rest assured - you dont have HCM as this is a congenital condition.Some of the marathon deaths have been attributed to pre-existing unrecognized HCM. In marathon you need to eject huge amount of blood out and if someone has HCM, the thickness below aortic valve prevent that output and hence complications.

Now, ECG is electrical record of heart activities from surface. The electrical conduction is happening in a wire system in inner layer of heart. If the heart muscles have hypertrophied because of endurance sport, you have a wall of thick muscles between the conduting wire system and surface electrodes. The shape of heart muscle is not the same as it was before. Understandbly that will change the orientation of electrical conduction in reference to surface electrode and hence change the axis.

Now think of adaptation of heart as a pump- In endurance sport, it has to pump blood more efficiently. For that it has to stay in diastole (blood receiving phase) longer. You can use a large Holi pichkari (those metal pichkari with piston) only when you suck the colour slowly upto its brim. So the frequency of sucking colour and then ejecting per minute becomes slower but more efficient. That analogy works with resting heart rate. And thats why low heart rate. One beat of heart on ECG is documented by P, QRS and T waves. The distance between this waves are seen in ECG as (PR interval, QT interval etc). If your heart rate is slow and one beat sustains longer, obviously the distance between individual waves will be longer. Hence prolonged P-R interval (which is known as 1st degree AV block), or increased Q-T interval. So any athlete having physiological bradycardia (sinus bradycardia, low resting heart rate) will have these intervals prolonged.

If the above blurb does not make sense, read 3-4 times (thats the way in medical science). If it still does not make sense- then take home message is - all the changes you mentioned are physiological and they are normal adaptations. Dont worry about them and keep running.

On the other hand, if your ECG shows second or third degree heart block or something known as LBBB (left bundle branch block), then dont ignore them.



Best

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