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Sudden heart attacks: Should the aging fitness buff be concerned?

sudden-heart-attack

Thinking about trying Ironman this year? Maybe a half-marathon to start? Or perhaps you’re just going to join a gym for the first time in a while.

Whether you turned twenty-one last week or you’re starting to think about retirement, us doctors simply love to prescribe fitness. Along with quitting smoking, sleeping more, and eating a healthy diet, it’s the lifestyle change we attach to many treatments. And with good reason – the power of fitness is undeniable.

It’s highly effective at preventing and treating many chronic diseases, with benefits to blood pressure, insulin sensitivity, memory, energy and weight. I even wrote about its mood-boosting influence in a recent article. In that piece I touched upon how beneficial exercise can be for your heart and lungs. It is vital to point out that the older you are, the more aware you should be of the risks very strenuous activity may pose. 

The dangers of strenuous exercise for older people

From US data we know that those who are choosing to exercise are in general likely to be older – 35 years-old and up. What is the significance of this? Well, older people, especially males, are at a higher risk than their younger counterparts of an unexpected loss of heart function, or sudden cardiac death, during strenuous physical exercise.

Older people, especially males, are at a higher risk than their younger counterparts of an unexpected loss of heart function, or sudden cardiac death, during strenuous physical exercise.

Let’s be clear, the risk is small and it shouldn’t deter you from exercising. But as the old adage goes, it’s better to be safe than sorry.

So let’s take a look at why aging fitness buffs are at a raised risk of a heart attack, and then consider how regular screening – in particular Ultrafast Heart scan CT or Calcium Score evaluation –can help mitigate this potential threat.

Understanding cardiac risk for older people

Within our ‘older fitness buff’ population, there are two main groups I’d like to focus on: those starting out and those who push themselves that extra mile. Of course, this doesn’t mean everyone else should ignore the risk, it simply means these two groups in particular are well analysed.

Here is what I tell my patients: When you are deconditioned, the fibres in your heart become like a dried up, old, and unused rubber band. If you suddenly stretch it, it breaks. If you gently stretch it several times, it regains its elasticity.

One study found that it was coronary artery disease (CAD) which was responsible for more than 80% of the cases of sudden cardiac death during sports-related activity in older people. CAD is an all-encompassing term for the build-up of cholesterol and calcium on the walls of arteries, caused in part by a poor diet, smoking and lack of exercise. Age is also a big risk factor, partly because those negative consequences have had time to accumulate, and partly because our arteries harden as we grow older. As calcium and cholesterol gathers, it can break off causing minor ruptures in the wall, which are then fixed by small blood clots. All these combine to narrow the artery. The same amount of blood is now trying to push through a smaller space, increasing the pressure, until eventually a big rupture occurs. The ‘plaque’ that breaks off then blocks the artery, causing a heart attack.

While regular physical activity reduces the risk of heart disease in the long-term, for those who already have signs of disease, the increased strain can paradoxically raise the risk in the short-term – that is, during exercise itself. This is of particular concern in the UAE, where rates of cardiovascular disease are some of the highest in the world, leading to 30% of all deaths.

One recent piece of research in the Netherlands really highlights how common CAD is, even in frequent exercisers, and how invisible it can be without the proper approach. In this study, 300 athletes were scanned – all of them were over 45 and showed no symptoms of CAD during regular electrocardiogram (ECG) tests. Incredibly, 19% turned out to be at risk of some form of heart attacks when further investigations were carried out, this time using CT scans, to ascertain the athletes’ calcium score. In fact, the recommendations from the study were that screening of all middle-aged athletes would be prudent.

One recent piece of research in the Netherlands really highlights how common CAD is, even in frequent exercisers, and how invisible it can be without the proper approach.

As for the true fitness buffs – the aged ultramarathon runner or Ironman triathlete – these people place a workload on their heart that is many times more than what is required (or recommended) to prevent heart disease. What’s important here is that older endurance athletes have a five-fold increased prevalence of an irregular heartbeat, also called an arrhythmia, than the general population. But why is this? The working theory is that extensive endurance exercise may ultimately have negative effects by stimulating changes to the structure of the heart and arteries. The body is adapting to the ongoing stress placed on its cardiovascular system. The strain leads to fibrosis, the medical term for ‘thickening’, of the arteries or heart muscle. Eventually the heart can begin to beat irregularly or its chambers can change in size.

Know your risk – no matter what your age

First, a note if you’re aged under 35. You might be feeling pretty good right now but while the risk of sudden heart problem is far less in young people, it still exists. In fact, in this population, the problem is less to do with heart disease and more to do with genetic abnormalities.

As a doctor I’m sometimes asked to assess cardiac risk in patients, especially those who are older and aiming to start exercising more.

If this is you, a useful place to start is the American Heart Association (AHA) pre-participation questionnaire. It assesses risk by asking ‘yes or no’ questions about, among other things, age, previous heart and chest problems, blood pressure, smoking, cholesterol levels and weight. Say ‘yes’ too many times and an evaluation by a physician is recommended.

A doctor will take a more detailed history and perform a physical evaluation. You may hear the words ‘Framingham score’ mentioned. This is a short form that uses the result of the evaluation to calculate the risk of a cardiac event over the next ten years. If considered high, a non-invasive scan or measurement may be recommended in an attempt to garner more information.

A common measurement is the ECG but while useful it doesn’t tell the whole story. A bad reading does not necessarily mean anything is wrong; a good reading isn’t proof of no problem. In fact, in the Netherlands study I mentioned earlier, where 19% of seemingly healthy athletes were at high coronary risk, all of them showed no sign of ischaemia (problems with blood supply to the heart muscles) on their ECG.

So is there a better solution?

Yes. The Dutch researchers went on to use a newer, more accurate, non-invasive assessment called a Heartscan CT which is useful for all types of fitness buff because it measures, among other things, calcium build-up and wall thickness. It’s also quick, taking just five minutes.

Lowering your risk

Of course the first step is advice you may have heard before: Avoid smoking, cut down on alcohol and sugar, and reduce stress. When it comes to exercise, it’s best to speak to your doctor first to ensure you’re doing more good than harm.

When it comes to exercise, it’s best to speak to your doctor first to ensure you’re doing more good than harm.

You may later wish to look into chelation therapy, where a chemical solution is administered into the blood stream to extract toxic metals. And as mentioned, the Heartscan CT for Calcium Score evaluation is quick and can provide accurate results. 

A small risk that’s not worth risking

Exercise is great. It’s fun, healthy, and makes you feel better.

But for some of us it also comes with a small risk. Revealing that risk requires just a brief assessment and scan. So, if you’re older and thinking of upping your game on the fitness front, the starting line should be your doctor’s office.

Mark Janowski

About Mark Janowski

Dr. Mark Janowski (MD, USA) completed his medical training at Georgetown University Hospital in Washington, DC in 2001. As a fully licensed internal medicine specialist, he focuses on the diagnosis and management of hypertension, diabetes, hormone disorders, gastrointestinal issues, cardiac issues, weight control, depression and anxiety. He is also experienced in bio-identical hormone replacement for men and women, and in conducting comprehensive medical check-ups to detect and reverse early heart disease and diabetes, as well as to reduce stroke risk. You can read more about our programmes HERE
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