Cycling Wed Exercise inflammation

Cycling Wed: I told you so…

Dear Endurance Athletes,

More than a year ago, I suggested that Ironman-distance triathlons were not heart healthy. Little did I know that expressing the notion that chronically inflaming oneself might cause permanent heart damage would be so controversial. This post led to my first experience with ad hominem comments. Obviously, talking about the upper limit of exercise is a sensitive matter.

I decided to write this reference-heavy iron-response, and then this follow-up post in the summer.

Today, a WSJ piece stirred the endurance-exercise world with much of the same information previously mentioned here. Now you know it’s real. The WSJ article quoted two soon-to-be published articles in the British journal Heart. I can’t comment on them yet, because they aren’t available. (A little strange.)

But I did find this 18 minute TED-talk given by sports cardiologist, Dr James O’Keefe. Be forewarned…The message might be disturbing to you. Maybe we aren’t born to run?


Ed note…I liked the reference to Pheidippides. Imagine the inflammation that would have been spared if he had ridden a bike to Marathon?

12 replies on “Cycling Wed: I told you so…”

GREAT talk by Dr. James O’Keefe (worth the time to watch if you are interested in the topic). Brings to mind the tragic story of Jim Fixx = author of the Complete Book of Running – only to die in 1984 from jogging with multivessel disease on path ( ) – which is eerily similar to Micah True’s story (Caballo Blanco) that Dr. O’Keefe describes (as well as to the “Pheidippides syndrome”). It makes sense that some exercise is good – moderate exercise is better – but extreme exercise (each & every day for long periods) may be fatal.

Reference was made by Dr. O’Keefe to increasing evidence of AFib in extreme athletes – which I know you’ve referred to. Just wondering what Dr. John recommends to his “addicted athlete” patients regarding the intensity of their training regimens when the athlete is “driven” …

THANKS again for posting!

As a person first diagnosed at age 62 (2 years ago) with asymptomatic, persistent afib (and an enlarged left atrium) in a routine physical, and having been an obsessive runner and weightlifter for many years, I find your posts on exercise, afib, and afib treatment interesting. In one of them, you mentioned Secretariat, the race horse. I decided to do some research on exercise and afib/heart issues. I thought race horses would be a great place to start. Horses don’t have opinions, affiliations to disclose, or an agenda. They just run. I was surprised to learn the high incidence of afib in race horses. Secretariat was not one of them. Secretariat died at 19 with a huge, healthy heart after being euthanized for a painful hoof problem. Poor horse, died earlier than the average 25-30 year lifespan. (Should have taken up cycling instead of racing… ha!). Anyway, I started obsessing about the damage I might have caused from long term exercising and at what level I should be exercising now. I then came upon the below article about the LONGEST- LIVING racehorse and I’ll tell you, I felt so much better. I think there is a lot to learn from horses.

Electrocardiogram from the Longest-Living Racehorse in Japan: Legendary Racehorse Shinzan
This paper describes the ECG obtained from the longest-living racehorse in Japan. The horse named Shinzan became the first postwar Japanese triple crown champion. (Shinzan was the best Japanese racehorse of the post-war era and became the first horse to win all 5 big titles of Japan including the Japanese Triple Crown). Although the horse died of heart failure on July 13, 1996 (35 years and 3 months old), we had recorded ECGs from the horse at clinical examination from time to time since December 30, 1994. The first ECG was recorded from the horse on December 30, 1994 and the diagnosis was atrial fibrillation. Atrial fibrillation was still present in the final ECG recording obtained with a Holter ECG recorder on May 17, 1996. It was therefore considered that the atrial fibrillation was of a persistent and not a paroxysmal type.

I found this web site from your Wall Street Journal comment on the to-be-published “Heart” (British journal) studies. The web site is very interesting; not only the medical science, but also your philosophy about surviving as a physician in the age of ObamaCare. I have colleague physicians all over the world, including in places with true socialized medicine (the U.K.) and it’s the same great job wherever you go. Both of my kids are medical students, and I feel content as a father that they’ll have rewarding lives, in all respects, and they’ll hopefully protect their parents from some of the ravages of a good, but imperfect health care system.

But I digress.

I’m 65 and currently training for the Surf City Half Marathon on Super Bowl Sunday. I’d been doing both overdistance (16 mile run at 8.5 min/mile pace two weeks ago) and intervals (e.g. 9 X 0.4 miles at 6:20 min/mile pace a couple days ago). I ran in my first road race in 24 years in Feb 2011 and finished 3rd in the 60-64 age group out of about 155 of my age group competitors in 1 hr 41 min. I didn’t run again until I started to train again last summer. I was hoping that, with more serious training than I did two years ago, I could go sub 1:40 and win my new age group (65-69). I was just about to greatly intensify my workouts for the next 6 weeks, before tapering for the race.

Alas, alas, alas. The Wall St. Journal article (and most of your website) certainly rained on my parade. Now I’m thinking that I should immediately cut back to 10 miles a week at no faster than an 8 minute mile pace and basically jog the half marathon (as I’ve already paid the $100 entry fee) and thereafter go back to lap swimming (I was a pretty slow varsity swimmer for good old U of L, many decades ago, and I really do enjoy both pool and open water swimming), supplemented by some resistance training in the gym.

aaaargh! This totally s–ks. I can’t figure out if I’m in denial, anger, or bargaining. Probably all three. This (news) has totally screwed up my plan for my life, which included outlasting my competition and winning some championships and finally fulfilling a long dream to do the Hawaii Ironman.

I understand that atrial fib is the biggest hazard. I wonder about the clogged arteries that you see in endurance athletes. Is this a function of diet…high volume/high intensity training necessitates a prodigious caloric intake. If one is eating 2 to 3 times a normal amount and it’s a lot of unhealthy calories, then perhaps this larger load of pathogenic lipids is responsible for the problems (I wonder, … hopefully).

And what about inflammation? (starting to think out of the box). Taking a clue from disease, there’s a new constellation of illnesses recognized recently, known as auto-inflammatory diseases (distinguished from auto-immune disorders by the former being a disorder of macrophages and neutrophils, while the latter are disorders of lymphocytes). The prototype auto-inflammatory disease is Familial Mediterranean Fever. A magic bullet for a great many patients has been colchicine (previously a cheap generic; now, unfortunately, a breathtakingly expensive proprietary orphan drug). Anyway, patients have taken colchicine for literally decades, with no untoward effects (and, interestingly, with superior cognition, when compared to matched cohorts, which might make some intuitive sense, were it to diminish intra-cerebral accumulation of amyloid — but I digress).

So I’m thinking that excessive-compulsive endurance training may produce a form of self-inflicted auto-inflammatory disease.

So maybe I could keep running, if I consumed the world’s most healthy diet and medicated with colchicine and low dose aspirin? (bargaining here).

But what can I do to avoid a-fib, … Doc?

P.S. I’m now recalling what I think was a French study, published a long time ago in NEJM. Study found that the risk of sudden death in MI was proportional to heart rate…low heart rates were protective.

At age 91, my father (resting heart rate at the time 36 — he’s a lifelong competitive endurance athlete — just turned 99 and still swimming a half hour a day — and stock market day trading on his computer 4 hours a day — quite successfully) had an MI half way through a one mile ocean swimming race. He finished the race, hiked the mile back down the beach, caught an ambulance to the hospital, where he was found to have 4 vessel total occlusive disease, along with elevated cardiac enzymes and diagnostic EKG changes. He has an emergency 4 vessel bypass and, 4 years later, set a world age group swimming record (200 meter backstroke; long course; swum at the annual summer masters long course swimming championship at the Lakeside Swim Club, in Louisville).

I also think that there is pretty unambiguous evidence for physical exercise being the most effective means of forestalling Alzheimer’s disease.

More bargaining.

I just HATE the idea that I can’t compete. Hate it. Hate it. Hate it.

– Larry Weisenthal
Huntington Beach CA

What seems to be lost in all your discussions is the recovery following a period of strenuous running, i.e. marathon. Your summary regarding the marathon rats included the following: “Scar tissue and arrhythmia susceptibility resolved after they stopped running.” And from the AHA Journal : “The fibrotic changes caused by 16 weeks of intensive exercise were reversed after an 8-week exercise cessation.” So taking two months of rest after completion of a marathon and training period beforehand is sufficient to reverse the damage to the heart. Sounds great. No need to limit oneself to 20 miles a week or no mile pace faster than 8 minutes per mile. Just give the body time to recover.

This is the 2nd sports related study that has shown up in the news before it is available through the Journals.

Also interesting that Dr O’Keefe has not mentioned the WSJ or the TED take on his twitter feed.

And now there is a UK Telegraph article, but it does not give any specifics. So it will lead to more confusion.

The fact that some elite masters athletes with decades of high mileage training never have any issues suggests that there is also a genetic component involved. This seems to get left out of the discussion. Analogy: Why do some runners suffer chronically with stress fractures, while others (training exactly the same way) do not. The point is this: instead of relying on statistics to decide whether or not I should train/race hard, why wouldn’t I get a periodic thorough heart screening (echo, CT-calcium-score, MRI) to see how my heart is responding to the high mileage. If the results show zero abnormal adaptations to the decades of hard exercise, the chances of me having problems are far less than most other things that I choose to do.

This is quite the controversial topic. I found the Runner’s World article ( refuting this study quite interesting. It claims the O’Keefe study controls for things like BMI, smoking, hypertension. Here’s an excerpt:

“What this means is that they used statistical methods to effectively “equalize” everyone’s weight, blood pressure, cholesterol, and so on. But this is absurd when you think about it. Why do we think running is good for health? In part because it plays a role in reducing weight, blood pressure, cholesterol, and so on. They’re effectively saying, “If we ignore the known health benefits of greater amounts of aerobic exercise, then greater amounts of aerobic exercise don’t have any health benefits.”

I’m not a doctor, but this does seem to be “manipulating the data” as Dr. Thompson says in the WSJ article (note: I am biased as I am a runner with a-fib treated by him).

My personal story is a perfect example of why you can’t cherry-pick specific things to test for, and why their conclusions don’t make sense. A former runner, I quit due to injury and a busy career, put on 40 lbs, started smoking, developed high blood pressure and borderline cholesterol. I did not sleep well and was stressed and tired all the time. One day a friend challenged me to run a 200 mile relay race (with 11 others) and I decided I needed to make a change. It’s been 3 years since I’ve had a cigarette, I’ve run a sub-3:00 marathon, my health stats, mood and energy are better than ever, and my only issue is a-fib (not really an issue now that I’ve cut caffeine and alcohol). I feel like I’ve increased my lifespan by decades. I understand that I could now use a dose of moderation in my training, but I’m just not wired that way (at least not for a few more years).

Thanks. Alex H is a gifted writer and teacher. He makes a compelling argument.

I’d argue that he and I agree almost 100% on this matter.

No one is saying that running or exercise isn’t healthy. Your case illustrates the essence of the issue. Of course, your embrace of healthy behaviors decreased your risk of chronic disease. And yes, I believe exercise should be vigorous.

The debate here isn’t about one marathon or one century. It’s about folks who have chronically inflamed their bodies and minds for years. It’s about those who rarely give themselves breaks for recovery, be they micro- or macro-cycles.

It’s about balance. It’s about common sense. It’s about explaining why CT scans of the heart’s of runners look like smokers. It’s about explaining why so many endurance athletes develop a heart rhythm disorder seen in obese subjects.

As a life-long slow-twitcher, I’m curious.

thanks for sharing this video and information.

I wonder why everyone is saying ‘you have to run slower than 8min/mile’ but not related to a heart rate number or heart rate effort which in my opinion is more important than “8min/mile” term – if someone runs 7min pace and that’s only 50% of his/her maximum HR then maybe 7min if fine. On the other hand everyday I see guys running 9min pace that seems too fast for them.

What is your opinion on it? Thanks

Wow, I came here from Tilford’s blog, which is the reverse of my usual pattern 🙂

I’d be curious to see just exactly what kind of shape Steve is in for one thing.

I’m VERY curious to read the upcoming paper, when is the embargo being lifted Doc?

And finally I guess, since I ride a bike and really despise running 😉 I’d be curious to see what, if any, data there is pertaining to cycling? This kind of makes me thinking that if I want to see a maxium HEALTH benefit, it would probably be wise to just putt around in Zone 2 all the time.

Wow. Stunning.

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