Cycling Wed Healthy Living inflammation

CW: Is the Ironman triathlon heart-healthy?

Before I even start, let me say this to my triathlete friends…

I really like you all. And…I am sorry for how I feel about your sport’s pinnacle, the Ironman triathlon. But I was poked into writing this post. When asked the question of whether the Ironman is safe for the middle-aged heart, what was I to do? Lie?

Each August, my hometown, Louisville, KY, gets overrun, over-swum and over-ridden with “Iron people.” No, these humans aren’t rust colored, or all that hardened, but they are indeed a determined lot. Triathletes, or iron people if you will, wake up before sunrise to swim, bike or run. Then they eat; some go to work (barely), and then they do the training thing again in the evening. Calling these athletes focused would surely be an understatement.

So it is each summer that I endure the same question: “Dr Mandrola, did you do the Ironman?”

“No…I just ride bikes.”

But this year was different. Before I could launch into my usual dissertation on how training for Ironman-length triathlons causes excess inflammation, coronary calcium, atrial fibrillation, divorce, etc, etc, another question quickly popped up.

“What did you think of that guy who died during this year’s race?”

It’s true; unfortunately, a middle-aged competitor suffered sudden cardiac death during the swim portion of this year’s race. The press reports were sparse, but the consensus was that he had a heart attack and drowned. Sudden death is not all that uncommon during triathlons. (A warning: don’t Google “sudden death and triathlons” if you are on the fence about starting up this hobby.)

I hate to hear about people dying during exercise. Not only is it sad, but it sends the wrong message.

But when asked about the heart-health of Ironman-length races, I have to answer truthfully.

Here’s the first thought that popped in my mind:

What’s even sadder to me, as a cardiologist and competitive athlete, is my suspicion that the possibility of dying during the Ironman will only heighten the race’s allure. I hope that I am wrong about this, but as a former triathlete (disclosure: only a half-ironman finisher), and an AF-doctor to many an over-achieving endurance athlete, I doubt that the possibility of death will serve as a deterrent.

So what do I think of a young man–with years of good living left–dying prematurely in the Ohio River?

It’s awful.

And for what did he die?

For a finisher’s tee shirt…or the prestige of having “Iron” status.

It perplexes me that people think emulating the whims of a few Southern California endurance-junkies is a good idea. That the strong-mitochondria-endowed Mark Allen, Dave Scott and Scott Tinley thought it was cool to swim 2.4 miles, bike 112 and run 26.2 in the 1980s doesn’t make it wise for the over-scheduled and middle-aged of today. These guys, like professional triathletes, own bodies that actually allow them to race each other over that distance. This is clearly not the case for the majority of people “doing” the Ironman now. Most regular iron people are slogging—or some would say flogging–through race day. (I know I did, and over only half the distance.)

I don’t get it. Call me jaded, envious, slow, snarky, or anything else you wish, but why is slogging through an inflammatory soup held in such high regard? Why is it surprising that doing so causes heart attacks, arrhythmias and divorce? This is healthy, really?

We all know that daily exercise is good, great even, but geez. And we also know that each of triathlon’s sports are compelling in and of themselves. But together, in one day, over that ridiculously long and whimsical distance? Why can’t we enjoy each of the three sports for their own elegance? For instance…

Swimming rocks! I swam regularly for years on a Masters team. The challenge of trying to master the craft of the four strokes keeps you coming back. Swimmers can also satisfy their fitness craving by working towards going faster. And who doesn’t revel in the perfect flip-turn? Or this hard to beat visual: diving in an outdoor pool that’s clouded by a pre-dawn morning steam. But swimming 2.4 miles before a bike ride and run? Wouldn’t breakfast afterwards be better, or healthier?

And the bike…you all know I love bikes! I couldn’t imagine not riding. The sensations generated on that human-powered machine are simply beautiful. Cycling is an infection that some catch and simply cannot rid themselves of. But riding in a straight line for five hours at 200 watts–with goo-bars stuck to the top-tube? Nope. I can’t imagine pedaling that long without a cookie stop that had a folk band playing.

And the run…Okay, I too was a runner that idealized the idea of a marathon. Here I see your point, as you can actually “race” a marathon. Though clearly, training to run a faster 5k or 10k would be healthier, a marathon can be achieved—by most–within the bounds of wellness. But who thinks it intelligent to prep for the marathon by swimming and biking immediately before?

Want a heart-healthier idea?

Start with not idealizing inflammatory endeavors that threaten your life. Just because the majority don’t die during the Ironman doesn’t make it healthy. I believe there are simpler feats that not only impress those of us athletes in the know, but might also make you live longer and better. Cool things like:

  • Swimming a fast and smooth 400 IM.
  • Riding me off your wheel in a 45-minute criterium. (Not that hard.)
  • Training your body to run a 10k one-minute faster than your best time last year. (Really hard.)
  • And why isn’t the Olympic-distance tri long enough? (It takes most mortals more than two hours to swim 1500 meters, bike 40k and run 10K.)

And if you could do all this and still need a challenge…

  • try touching your toes without bending at the knees,
  • or writing a blog without a grammatical error,
  • or this elusive challenge…sitting still long enough to read a book.

My friends and colleagues, I submit to you that these seven softies would surely make for a happier, healthier, albeit less Iron heart.


32 replies on “CW: Is the Ironman triathlon heart-healthy?”

This was an incredibly excellent post. I would compare exercise to oatmeal. Bare with me. Like oatmeal, exercise can be beneficial to your health. However, in excess, it can be very pro-inflammatory and cause much more harm than good in this instance. The ironman is no different than a heaping portion of exercise that one body just can’t benefit from in such a short period of time. I am from Louisville, I’ve cycled 400 miles in four days, I’ve run in mini-marathons, and I exercise frequently but nothing about a tri appeals to me besides the story you could tell others (if I survived).

Nice post from a cyclist about triathlons. I absolutely agree with his comment about the Olympic distance triathlon being a great distance. I am not sure why people feel the need to race in the Ironman distance. However, I was hoping for an article from a heart doctor about the risks of ironman verses other distance triathlons. Tell us about all of the Ironmen that have to be given IV fluids after the race. Tell us about the Ironmen who you are admitted to the hospital after the race with heart conditions….
Everything that I have read seems to indicate that the deaths in a triathlon occur in the swim portion of the race. In fact, in one larger study, 14 of the 15 deaths were in the swim with the other triathlete death in a bike crash (probably the one in Louisville where a driver was drunk at 7 am in the morning and ran over a triathlete on a bike). Based upon the statistics, the 112 mile bike and the marathon don’t seem to be any more dangerous than by themselves. In addition, I have not seen anything to indicate that the Ironman distance swim (2.4 miles) has an increased risk of death relative to a 400 M open water swim. I happened to witness the water rescue of the IM Lou athlete and the subsequent attempts to revive him. It was very sad and a sobering experience. However, the triathlete died in the first 400M of the race. Again, this seems to point to the stress and anxiety associated with an open water swim. I would like to see a study that looks into the experience of the triathletes who died and race conditions surrounding their death. Open water races are very scary and should only be attempted by experienced swimmers with training in open water race conditions. Also, the USAT should look into ways to reduce the stress in the open water part of the race.

Yours truly,

I am NOT an Ironman.

First let me say that I’m sure everything in your blog is factual. I’m not as wise as you doctor guys so I’m in no position to debate your opinion or your findings. With that said I’m sure that the Ironman distance is not healty for the heart and cause all the tribulations you point out but it sure beats laying on the couch. Yes I did the Ironman in 2010. Yes I’m a bit past middle age (58). Why did I do it? To see if I could. For the cool T-shirt, but mostly for the challange. Along the way I met some fantastic people with the same disire as me. Will I do it again knowing that it may cause heart problems? Absolutly! I also race in Xterra events going down single track trails on my mountain bike knowing a wrong turn could end in a crash that would break an arm or leg or head but I’m not about to give that up. So I’ll continue to “slog” through my next Ironman and hope all goes well with the ticker, if not in the words of Evel Knievel “my death will be glorious” or at least not dying of a heart attack being 60 pounds overweight.

(Disclaimer: 2x Ironman from Louisville) You make some good points but you’re making the wrong argument. None of us doubt that Ironman carries some rather serious risks. For us, it’s not about the exercise or the fitness. It’s not about the t-shirt or the 140.6 sticker. Those are the secondary benefits. It’s about seeing how far you can push yourself. It’s about finding out something about yourself that most people never do. Yes, doing so is risky. We fully understand that and appreciate it more than most people will ever know.

I didn’t know the deceased and don’t dare presume to know his state of mind but from what I’ve heard about the tragic event, he knew the risks and died doing something he enjoyed. I can think of much worse ways to go.

One other thing: you suggest Olympic distance triathlons as an alternative. The individual who died at IM Louisville did so very early into the swim. The same thing would have happened at an Oly event. Again I’m not a medical professional and don’t dare make assumptions about his condition but it the “Iron distance” absolutely wasn’t a factor. It could have just as easily happened during a “fast and smooth 400 IM” or any of the other alternatives you mention. Again: you’re making the wrong argument.

For a cardiac electrophysiologist and for a blog post entitled “Is the Ironman heart healthy” you sure don’t provide much medical information on why this is bad. Instead you are coming off as a bitter, possibly divorced ex triathlete.

Bitter? Possibly divorced?

I didn’t get those things from this post.

What I got was that in the pursuit of better, we often screw up good.


Pursuit of better??? Not once in this post did I get anything from him that would indicate pursuing an IM dream in his opinion is anything but crazy and irrational.

He mentions divorce couple of different times like it’s a side affect of doing an IM distance event.

“Before I could launch into my usual dissertation on how training for Ironman-length triathlons causes excess inflammation, coronary calcium, atrial fibrillation, divorce, etc, etc, another question quickly popped up.”

“I don’t get it. Call me jaded, envious, slow, snarky, or anything else you wish, but why is slogging through an inflammatory soup held in such high regard? Why is it surprising that doing so causes heart attacks, arrhythmias and divorce? This is healthy, really?”

“It’s about seeing how far you can push yourself. It’s about finding out something about yourself that most people never do. Yes, doing so is risky. We fully understand that and appreciate it more than most people will ever know.”

Well said Toby J. Personally I refuse to live my life ‘playing it safe’ or not pushing limits in pursuit of reaching my potential. I can also relate to Kevin B’s comment:

“at least not dying of a heart attack being 60 pounds overweight.”.

How many people will spend the amount of time I train (or more) watching TV and do just that (die overweight and unhealthy)? I think we all know that number will dwarf the number of triathletes that die competing. I also suspect few people have ever learned much about themselves let alone reached their potential watching TV.

(Same disclaimer as Toby – 2x Ironman from Louisville)

I understand the argument you are making and I am sure as a medical doctor you have valid concerns. However-you yourself are a 70.3 finisher. There are risks there too. There are risks in a 5k, a 10k, in ANYTHING you do. More people are being drawn to the sport and unfortunately, not everyone is physically prepared in the way that they should be. THAT should be the focus of your article. I am going for IM #2 in a few months and why am I doing it? Why did you become a doctor? Because it was easy, because anyone could do it? No, because it is hard, because it is special.

Not sure why you think some activity is better than others. As a pacemaker rep I am also concerned with the idea of extreme exercise but then again I look at the stress that was created by me as a pacemaker rep. I was always the last to be called, always the first expected to be there, never slept and I found that to be much more stressful on the body than triathlons.

It is ok NOT to have the triathlon bug – clearly you don’t. Personally I never kept a finisher’s t-shirt or a medal – maybe that is what some do it for but I can assure you that finishing an Ironman is always one of my most gratifying experiences. When you finish a marathon or half-IM you can do nothing but smile. When you finish an Ironman you are more likely to cry.

Life isn’t about tip-toeing around every little danger. It is about living your life to the fullest and sliding into the grave just as the engine dies and the wheels break off.

John, I think if you adjusted your schedule a bit, get a few more laps in the pool, knock out a few century rides next summer and increase your long run you could make that final turn to 4th Street Live and hear Mike Reilly announce “JOHN MANDROLA -YOU ARE AN IRONMAN”. Now you got to admit, that would be pretty cool! Then when people asked if you did the Ironman you could answer “Damn straight”.

Not to change the tone here but….after growing up in the pool swimming competitively, running through my younger adult years….I now am known as just a cyclist…with a pacemaker. I don’t believe I’m settling when I set goals like biking 5-6000 miles a year, 500 across Iowa in 7 days, 100 in a day in the 110 intense heat of August in Texas. I’m happy with that b/c I sink like a rock when I get into the pool these days, and would rather poke out my eye if you told me I had to run anywhere. But there is nothing that replaces the feeling when riding a bike. But like John, I prefer a cookie stop now and then with a folk band….and if you through in a couple 8-10 year olds standing along side the road giving out high-fives as you ride into said cookie stop….well that my friend is icing on the cake!

Dr. Mandrola;
This article is an atrocity of subjective speculation. Please don’t get me wrong. If I were in a cath lab as a patient, or in a hospital in a cardiac setting, I would regard your opinion with utmost respect, but seriously, this writing should be nominated for an award in persuasive speech. You cite NO clinical research. You address none of the variables at play in the question, “Is Ironman healthy?”
As a medical doctor who is highly respected in this city, people listen to you. However, when you throw your opinion down on paper without proper research and backing, I have a serious problem with it. Where is the clinical evidence? Your article is titled, “Is Ironman Healthy?” however, you don’t once use a smidgeon of ANY clinical evidence to back up your rambling. How many people have been encouraged to lose weight due to their “Iron” aspirations? How many Iron athletes have introduced and encouraged others to lead healthier lifestyles? There are SO many variables at play in the question in the question, “Is Ironman healthy”, and you address none of them!
True, some individuals may experience negative cardiac symptoms and conditions as a result from their Ironman training, but how many more experience positive results from their training?
That is the beauty of training for Ironman, learning to find balance and true health and wellness! Many athletes suffer from overtraining syndrome, and overtraining will definitively impede performance. So to truly study performance and training, a good athlete would not be doing any damage to their heart, because they wouldn’t be overtraining and experiencing these s&s such as Atrial Fib, etc.
Please remove this article until some true hard research is done. I respect you as a cardiologist, but don’t talk about something you haven’t clearly researched. That is just immoral.
Troy Shellhamer

You ask why isn’t the Olympic distance good enough? During this years NY Olympic triathlon a 64-year-old man died after having a heart attack during the swimming leg and a 40-year-old woman also had a heart attack during the 1,500-meter swim. I am not a doctor & there probably is a clinical reason why the majority of people die in the swim but it seems to me that if you have a cardiac event during the swim & lose consciousness there is a good chance you are going to die. Not because of poor fitness but because we are not fish.

I too would like to see data backing up your article. One thing I would be interested to know is how many people have had a cardiac arrest during a running event yet survived because they were seen & given CPR quickly.

As triathletes we understand the risks & while none of us thinks we will die competing or training sometimes just that happens. Sad as that may be.

My heart goes out to all these families for their losses.

You had me, Doctor, until you subjected, “emulating the whims of a few Southern California endurance-junkies is a good idea.” At that point, I dismissed your position as nothing more than a jab at the origins of Ironman. Let it go and try again.

Very well written! However, I too was hoping for a little science. As a Pharmacist and 3x Ironman with the 4th to be next August, I would love to here the supporting documentation for the claim that IM causes A-Fib? I spend a lot of time trying to stay current with the cardiology literature and I’ve not seen that claim made anywhere. According to AHA 2.2 million people are living with A-Fib. In the US there are 8 IM races/year with 2500-3000 people per event. So what % of us end up with A-Fib? Contrast that with the % of non IM competitors? I would submit that the American diet/lifestyle is much bigger problem.

it’s the old ” living causes death” thing. if you want to feel whole by whatever may make you feel good. there’s always that chance that old grimoooo…. may come along and do you in. let dr. have his say, don’t put him on the defensive.

dr. when will we hear from you re the new fda approved ” xarelto ” and how does it compare to ” “pradaxa” in all ways but most of all in reversibility. carrying around my charcoal bricket is getting old. thanks.

It was great to read this! It has been many years since I have seen you. I remember when you did triathlons and when you did Tom
Sawyer tri with your family as a relay. I thought then how wonderful that was, when everyone is always racing you gave that up to share the experience with your family. I admired that. I have always loved going the distance but my family is more important. I cannot always do as I please, which would be to run all day. Thank you for sharing. I hope your family is well.

I did Louisville this year for my first IM. I was standing by the steps when they rolled this guy by on a stretcher, and it was sobering. However, there has been no story that this person entered the water on a whim, untrained.

BUT, based on his death in 8 minutes of swimming, he could have been dead doing any of the other workouts you suggest. There is no way he was going to complete an Olympic swim in that 8 minutes. Rarely is anything great accomplished, even safe things, without someone asking what is possible and “am I the person to make it possible?”

Going in, I knew that I would be exercising twice as long as I had ever done before (time = 16:13) and considered the real possibility that something bad would happen to me during that long day from a health perspective. I was so out of shape 2 years ago, I could not run a mile without a break. When I started having symptoms of any problem late in the day, I slowed down and payed attention to my body. The thing people need to balance is whether they are trying to make their lives more worth living or stuck in the mire of mediocrity because of their own fear or complacency.

As a malpractice attorney who defends doctors, my time is filled dealing with people who are upset because they have ruined their health with complacency and then get mad when a doctor can’t just fix their bodies like a mechanic fixes cars. Unfortunately, some people will pass their safe limits without any awareness that they are close to those limits. That should not stop people from pushing them. There are athletes that do 100-mile runs and several times the iron distance over the course of a day or weekend. That doesn’t mean all, or even many, others should try the same, but I applaud anyone who has the courage to step up and push themself to have a life that is more rewarding in their own eyes.

I had just started doing tri’s and had to have a schwannoma tumor removed from my spine and then got breast cancer at age 38. No family history, fit lifestyle, etc. I can’t wait to do an Ironman! Who cares if it’s a risk! You don’t get to pick what you get in your DNA and you never know when your health will be snatched away from you, even if you play it safe. Sitting on the sidelines for the past 3 years sucks. Tell your family how much you love them everyday and do your thing with no regrets!

As a former afibber I appreciate all of your blog posts, and the reality of this post is no different. Though I do understand where the apprehensive and callous nature of some of the responses come from, no doubt due to lack of information, I concur with all that you have written.
Having spent close 2 fifteen years of my life competing and living with the affib demon I also spent a great deal of time researching and trying to understand the nature of the beast (causes, triggers and solutions, along with my own personal ideas and trials). I also have 4 personal friends of similar lifestyles that also have dealt with affib as well. There is no doubt that the nature of my cycling and racing contributed greatly, not only to the onset of affib but the accelerated nature of it as the years progressed. I can only imagine, had I added running and swimming to the mix, what might have happened.
Thanks again and Blog-on.

Response to above post: When writing an obviously inflammatory blog post of this nature, specific statistics and data are required. A blog post simply striking fear (without supporting and detailed information) into the hearts of would-be and current triathletes will NOT change anything and in fact may encourage people further. If this blog post is truly aimed at informing, it needs to be a complete and thorough analysis of potential health issues, not just a rant.

So we have three broad group responding to this blog.
1. We agree with Dr. John. 2. We believe that Ironman is next to Godliness, we understand the risks and we’re prepared to accept these. 3. Ironman IS God and don’t you dare question my faith!

My perspective: John, you could just have easily have discussed any ultra-endurance activity and it’s effects on the ticker. I don’t think it (the heart) discriminates based on the modality that the limbs are undertaking. Our hunter/gatherer phenotype has led to a “safe” cardiorespiratory capacity of around 1-2 hours at below or around the anaerobic threshold intensity. I can’t imagine our primitive ancestors chasing an animal for 8-16 hours at high exercise intensity levels. I could, of course, be worng though because i haven’t cited a peer-reviewed article on the topic!!

Seriously, give John a break, all of you who have their knickers well and truly knotted by his comments. Blogs are not intended to replicate scientific journals. He’s got something interesting and informative to say and he’s a busy boy. If you’re not sure about the content of his blog ask a question (as some have done) or cite your own research to refute.

I couldn’t have said it better than Simon. And I’m guessing that DJ blogged about Ironman (instead of some other endurance event) because it’s poignantly topical right now.

Thanks Doug- we also had a 30 yo die on the finishing line at our local (Perth Western Australia) marathon a few weeks ago. I usually tell my athletes and patients (i’m an Exercise Physiologist) that it is the underlying cardiac condition that kills these individuals rather than exercise but in the case of UM events, as discussed and referenced by DJ, i’m not so sure.

All true-But as a doctor, his opinion is taken especially seriously. Plus, you post on a blog, you are indeed asking for comments/feedback and quite possibly some people who don’t like/disagree/get angry with what you say.

informative, well written. meant to inspire thought ( i know it did for me) not as an ultimatum or absolute dogma. perhaps we would do well to note and remember that and consider the thought provoking side to “over exercising”, if we feel differently or choose to ignore that is also good cuz it reminds us we live in a free country with the freedom to do as we wish. I appreciate the perspective and many of the thoughtful comments that followed, those who are “mad” about it need to consider that it is just a blog with an underlying good intention and if they disagree i am sure we all wish them good luck in their sport of choice.

Dr. John,
I appreciate your warnings about the Ironman competitions. I also enjoy the comments of the other readers.
I am a newbie to triathlons. In fact, on October 30th, I am entering my first – the Tinfoilman Triathlon at the UofA in Tucson. It is a sprint triathlon with a 825yd. swim, 12-mile cycle, and 3-mile run. This event is a special undertaking for me since I was sidelined for 8 years with a heart condition (Cardiac Syndrome X) that was masked by pericarditis. Please see my blog to learn more about me: I welcome your comments and advice as I approach these last 6 weeks proir to the tri. Above all, I agree with you: Enjoy each activity for what it is. “Slow and steady wins the race.” – or, at least I may complete it with a smile.
All the best,

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