The Heart Healers (45 page)

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ARGUABLY THE MOST
strenuous of all athletic competitions is marathon running. In 490 BC, Persian King Darius sent his powerful army to attack the Greeks at Marathon. Pheidippides was a forty-year-old Greek courier who ran to Sparta to ask for support. Over two days he ran 150 miles. Arriving at the Marathon battlefield from Sparta he was amazed to learn that the Greeks had defeated the Persians. He ran the 26.2 miles back to Athens, extended his arms in exaltation, and proclaimed, “Joy to you, we’ve won.” Pheidippides then collapsed and died. In 1879 Robert Browning’s poem “Pheidippides” inspired founders of the modern Olympic Games to invent the 26.2 mile marathon. Pheidippides’s death is the first report of sudden cardiac death in a long-distance runner.

The London Marathon is a public spectacle. I love the camaraderie that envelops the entire city, the sweaty runners, the pubs’ cold beer, and the sin of deep-fried fish and chips. Loosening up at the starting line of the London Marathon on a crisp April 2012 Greenwich morning was thirty-year-old Claire Squires. With her hair pulled back in a ponytail to reveal fine facial features and a gorgeous smile, Claire was slim and fit, looking forward to a soggy embrace with Simon Van Herrewege, her boyfriend of three years, who waited at the end of a serpentine 26-mile-385-yard course. In the meantime she would have a glorious tour of London past hundreds of thousands that lined the streets, before ending her run in St. James mall near Buckingham Palace.

Claire was one of 37,000 people taking part that year. Claire was a fitness buff, having both climbed Africa’s highest mountain, Tanzania’s Mount Kilimanjaro, and run in the London Marathon the previous year. This year was special. She was running for the Samaritan Charity to honor her brother Grant, who had died of drug overdose at age twenty-five, and for her mother Cilla’s twenty-four years of Samaritan volunteer work. From Greenwich, Claire headed east toward the halfway point at Tower Bridge, continued along the Thames River into Canary Wharf, then wended west into the final leg of the race, past the Tower of London. Nearing the finish she glimpsed London’s iconic Big Ben and Westminster Abbey as she prepared to turn onto Birdcage Walk for the final 385 yards of her run. Soon after turning, Claire stumbled and fell. She lay motionless on the ground. First responders attempted cardiac resuscitation. An ambulance transported her to the hospital but to no avail. Her death was the tenth in the London Marathon since it began in 1981, and the first since a twenty-two-year-old fitness instructor died in 2007. Autopsies revealed that at least five of the prior fatalities were attributable to undiagnosed heart disease, of which four were CAD. The next day Claire’s lovely smile graced every English tabloid. The tragic loss of such a young vital life deeply moved Londoners. Donations to Claire’s charity rose from 500 pounds to 1 million pounds in the days that followed, as Claire was buried next to her brother.

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CLAIRE’S DEATH RAISES
the question of how often sudden death occurs in athletics and how it might be prevented. Italian studies suggest the sudden death rate in strenuous competitive sports is about 1 in 50,000 athletes. Similar numbers have been compiled in the United States by the National Collegiate Athletic Association. The incidence of sudden cardiac death in college-aged athletes is 1:43,000. The risk varies widely with both ethnicity and sport. At higher risk are male athletes (1:33,000), black male athletes (1:13,000), and male basketball players (1:7,000). The basis of these wide disparities is as yet unexplained. Intense physical exertion in athletic participation does increase the risk of sudden death. An Italian study reported a 2.5 greater risk for youth participating in sports compared with age-matched noncompeting population. But striking as these numbers may seem, they are arguably misleading. If we look at risk during the period of exercise, it is much higher. Swedish investigators studied risk in 926,000 competitive cross-country skiers over ninety years. Although the absolute risk was similar to runners, during the period of skiing itself the risk of sudden death was a hundredfold higher.

We now have a database to assess the rate of sudden death among marathon runners. In
The New England Journal of Medicine,
researchers from the Massachusetts General Hospital reported that 2 million people run in marathons and half marathons each year. The number has more than doubled since the turn of the century. The investigators used the Race Associated Cardiac Arrest Event Registry (RACER) database to determine the incidence of sudden death during or within one hour of completing the race in the United States between January 1, 2000, and May 31, 2010. Among 10.9 million marathon runners 59 experienced cardiac arrest. Their average age was 42; 86% were men. The rate was 1 in every 184,000 runners. Cardiac arrest was higher in full-marathon than half marathon participants, and higher in men than women. Senior investigator Dr. Aaron Baggish saw the results this way, “You’re much less likely to have a cardiac arrest as a middle-aged marathon runner than you are as a college athlete, as somebody who’s doing triathlons, or even as somebody who’s out doing casual recreational jogging.” From the Italian and American databases, roughly one in 50,000 to 150,000 marathon runners will experience a cardiac arrest. The New York Marathon now has almost 50,000 participants yearly, so we should not be surprised when an event occurs.

How should we screen an athlete for his/her risk of sudden death? For nonprofessional athletes, we have no agreement among recognized authorities. At one end of the spectrum is Italy, where athletes are not permitted to participate in minor sports without having had a medical history, physical examination, and ECG. Data from the Venice region of Italy, where athletes at all levels are banned from competition based on potentially hazardous conditions, clarifies these issues. The program slashed the number of sudden cardiac deaths in athletes by 90%—from 3.6 per 100,000 person-years in 1979/1980 to 0.4 per 100,000 person-years in 2003/2004. To achieve this result, the program disqualified 2% of all athletes. We can calculate that for every death prevented, about 1,000 athletes are needlessly banned from competing.

Whereas Italy has focused on preventing sudden death, North America has emphasized the limitations of cost and access, and the fact that false positives would send an unknown number of healthy kids to the sidelines. A study in the November 27, 2012, issue of the
Journal of the American College of Cardiology
calculated the Medicare reimbursement rate for the cost of pre-participation physical exam and ECG screening to be $263 per athlete. Projected for 8.5 million U.S. athletes the authors estimated that this program would cost more than $10 million per life saved, and that if followed for twenty years, it would cost $50 billion to save 4,800 lives. The numbers were disputed by an editorial written by Dr. Antonio Pelliccia of the Institute of Sport Medicine and Science in Rome. Pelliccia says ECG screening in Italy’s mandatory screening program costs $60 per athlete, which most athletes can afford, and that it is reimbursed for those unable to pay. The American Heart Association and the American College of Cardiology and the Canadian Heart and Stroke Foundations do not recommend the use of ECGs for cardiovascular screening of athletes, whereas the European Society of Cardiology and the International Olympic Committee do.

Squires’s death in London reignited the controversy over a universal screening approach for the 10,000 athletes in the upcoming 2012 Olympic Games. London cardiologist Sanjay Sharma, who heads the only sports cardiology clinic in the UK, screened the entire cadre of 1,000 potential English Olympians on thirty-two different squads, with the aim of identifying conditions that could potentially cause sudden cardiac death. Sharma’s team identified 2 athletes with an abnormal extra electrical conduction pathway called Wolff-Parkinson-White syndrome, a known cause of sudden death. The athletes were told they would be required to have a catheter treatment to destroy the extra pathway before competing in the Olympics. At the same time the International Olympic Committee recommended that all countries conduct ECG screening, and if it was questionable, additional tests be considered. Most commonly the logical additional test would be an echocardiogram.

Dr. Sharma makes two arguments for this more extensive screening: “Our own experience of screening high-level athletes is that about one in one hundred has a condition that is congenital and could potentially cause problems later in midlife—such as heart failure or the heart becoming hypertrophied. And one in 300 harbors a condition that could potentially kill instantly.… Sadly, only 20% of athletes with these conditions manifest any symptoms whatsoever. Sudden death is often the first presentation.” Furthermore, he argues, “we spend millions and millions on octogenarians to get back two or three years, and nothing on the youngsters to get back seventy years of life.”

Among elite athletes in professional sports, those competing in basketball, football, soccer, and swimming are at increased risk. For this reason, professional athletes in European and American soccer and in the National Basketball Association, National Football League, National Hockey League, and Major League Baseball now all have screening ECGs. For the London Olympics Sharma positioned at least one automated external defibrillator for every mile of the marathon, and added bicycle responders in between carrying defibrillators. As Sharma says, “We need to get to that individual within two minutes if they are in ventricular fibrillation. With the system now in place, I believe the same protocol should now be done in the London Marathon.” Think of it this way. With roughly 40,000 runners, we should expect a cardiac arrest every two to four years. I agree with Sharma that when defibrillation is applied very rapidly in a heart too good to die, the victim has a very good chance of full recovery. The 2012 Olympic Games had no cardiac arrests among the world’s athletes.

And so we come to the critical personal question. Assuming that you or a loved one competes in athletics, do you deserve the same consideration as the Olympic and the professional athletes, particularly since your risk may be higher than a conditioned athlete’s? As public policy an ECG and echocardiogram for every athlete would destroy our health-care budget. On the other hand, I do feel that if you are competing in a strenuous sport and are willing to pay for the tests, an ECG and possibly an echocardiogram is not an unreasonable investment. The risk is quite low, but of course the return may be quite high.

How bad is living at the other end of the spectrum, a sedentary life? In 2014 a study in the
Journal of the American Heart Association
funded by the Spanish government reported the outcomes of 13,000 healthy young university graduates, average age thirty-seven, followed over eight years. During that period 97 deaths occurred, less than the expected number of the Spanish population of the same sex and age. The striking finding was that watching television for more than three hours a day was associated with a twofold increased risk of premature death, compared to less than an hour per day. Dr. Miguel Ángel Martínez-González of Pamplona’s University of Navarra concludes, “Our findings suggest that 1 or even 2 hours of television viewing is OK, but spending more than 3 hours watching television is probably not a good idea.” How relevant are these data to our daily lives? Other studies have shown a correlation between hours of TV viewing and the development of diabetes, the risk of CAD, and mortality. Perhaps it depends on what you do when you sit: the investigators found no association between either time spent in front of a computer or driving time and mortality. Dr. Martínez-González speculates that, “Because television viewing is likely to be associated with snacking and consumption of sugar-sweetened beverages, a possible explanation could be a difference in energy intake.”

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I CAN SPECULATE
what would have happened if my friend Donald had not changed his lifestyle. When diet and exercise are ignored, we run the risk of obesity. In early 2012 the Institute of Medicine, a nonpartisan organization of medicine’s leaders, drew the depressing conclusion that obesity “constitutes a startling setback to major improvements achieved in other areas of health during the past century.” Two-thirds of adults and one-third of American children are now overweight. In the United States in the mid-1980s the prevalence of obesity in every state was less than 20%; today it is greater than 20% in every state. In Mississippi, the fattest state, 32.5% of adults are obese. The twentieth-century was the smoking century, the twenty-first is now the obesity century. The annual cost of illness related to obesity in the United States approaches $200 billion.

We are now for the first time seeing adolescents with type 2 diabetes, essentially diabetes caused by obesity, a disease that previously only occurred in adults. In May 2012 the Centers for Disease Control and Prevention published a survey of 3,000 youths ages twelve to nineteen. An astonishing 21% of the adolescents had already had diabetes or pre-diabetes, and fully half of overweight teens had abnormal levels of blood pressure, blood cholesterol, or blood sugar. How did this happen? More than 90% of diabetic adolescents eat more than the daily recommendations of saturated fat and one-third watch TV for more than two hours a day. These are the risk factors for a heart attack. We know that kids at risk become adults at risk. Earlier I said that I was certain that the Million Hearts initiative is achievable; I did not say I was certain it would be. Our kids and their permissive parents are doing us in. If you have a significantly overweight child, take care of him/her. It’s what parents do.

The handmaiden of obesity is diabetes. Most diabetics die of cardiovascular disease. How does diabetes lead to CAD? After we eat, our blood level of fat and glucose (sugar) increases, triggering the release of insulin. Insulin is the body’s deliveryman, responsible for clearing fat and glucose from the blood into the cells. When caloric intake exceeds energy expenditure, however, glucose and fat do not get cleared completely from the blood. The persistent elevation of glucose and fat triggers continued insulin secretion. The body’s cells compensate for persistently increased blood level of insulin by becoming resistant to it, aggravating conventional risk factors like high blood pressure. Good HDL cholesterol falls and bad LDL rises. High levels of bad cholesterol lead to it being trapped in the blood vessel wall as the low levels of good cholesterol reduce cholesterol egress. After years in this condition, the pancreatic cells, which synthesize insulin, become exhausted. As this happens full-blown diabetes emerges.