CW: Athletes teaching heart rhythm doctors?

What could competitive athletes teach a group of heart rhythm specialists?

Cyclists, runners and yes, even triathletes, know something that we wizards too often forget. I’ll tell you what it is in good time. Keep reading.

I just returned from a giant gathering of heart rhythm doctors. It was, as all national meetings are, an incredible learning experience. You come back motivated and ready for action. (The cycling equivalent would be watching tapes of Paris-Roubaix before a big crit. For tri-peeps, think of the Dave Scott/Mark Allen duel in Kona. Seriously, that was an epic battle of inflammation.)

Sub Q ICD

My Heart Rhythm Society really knows how to put on a show. They recruit wonderful speakers, accept exciting scientific papers and hold too-numerous-to-count practical sessions for us regular docs. And…as an industry-intensive specialty, all the latest innovative technology is available for hands-on exploration. Just walk up to a booth and in seconds you are holding a futuristic ICD—one without leads in blood vessels!

But for all the glitz, I continue to be disappointed in the lack of interest in my passion—the advocacy of healthy living through good choices. Athletes understand this well, but us tech-heavy doctors, not so much.

I found not one abstract, poster or oral presentation on the importance of fitness, healthy lifestyle and what smart people like to call primordial prevention. Heart rhythm doctors crave news about burning, installing and medicating a disease that’s already happened. It’s ironic that much of what I treat day in and day out may have been prevented.

An athlete wouldn’t think about not exercising every day. You punish yourself for eating a cookie. You like sleep because it makes for better muscle recovery. Some athletes even have rules about drinking Coke: I’ve heard nutjob cyclists who allow themselves a cold Coke only when two criteria are met: after a hard-fought bike race or after a three-hour training ride.

Lots of small choices pay big dividends.

I saw this patient recently (a former athlete gone soft with birthdays) who has been introduced to middle age by the new onset of atrial fibrillation. I saw her for consideration of catheter ablation. Really? That fast? Not in my practice. My patients get the lecture before this:

That's a lot of burns!

She has done well managing her disease: she cut down on caffeine and alcohol, improved her sleep hygiene, carved out time for exercise and now focuses on avoiding last-minute cram sessions for projects. Her arrhythmia has improved without medicines and based on these good choices, an invasive procedure was wiped off the table. Granted, it doesn’t always work this nicely. But sometimes it does. This blawger’s opinion is that doctors too often underestimate the value of athletic lifestyle choices. Rather, we do the easy and evidence-based thing: pull out the prescription pad or recommend procedures.

Imagine the effects on public health if young people implemented this patient’s strategy. Remember, the same behaviors that prevent atrial fibrillation also lower blood pressure, control blood sugar, modulate cholesterol, improve cognition, prevent cancer and even help the environment. It’s a tired analogy to invoke auto maintenance; but it’s true. Electrical disorders frequently result from years of poor body maintenance.

Though we heart rhythm doctors bask in technology and worship engineering prowess, we must remember that we are still doctors. We have the capital to influence our patients’ decisions. We aren’t their moms, but we can be their teachers.

Athletes do the little things. They know the benefits of good preparation and long-term maintenance of the only body they will ever have. As an athletic doctor, I want to teach my patients that. I want to write about it. I love technology, and the fury of medicine, but I also love it when I don’t have to use it.

JMM

14 comments

  1. THANKS John. You are an AFib doctor with a primary care (and athlete’s) mindset. Hard to get others in your group to “believe” unless they themselves “live” the important messages you speak of.

    I often wonder how much disease would be mitigated by simply adopting healthy lifestyle choices …

  2. So John, when are you going to give this lecture to the BMA docs? Or have you already and I missed it? Seriously, you need to get on the Network agenda!

    1. Not yet. I stand ready and able to promote and advocate for minimalism and healthy living, to anyone who will listen. Thanks for the support.

  3. Hi John, I like this post a lot. Hard question, though – would the society have been so receptive to patients who weren’t “successful athletes”? What if they’d been cranky, tired-looking women, or vets w/ something like PTSD? (I’m not sure.)

    1. Thanks for the nice words Elaine. I realize that I oversimplify complicated matters. But seriously, I’ve been going to AF meetings for a decade and there’s never a mention about lifestyle. Yet one of the strong messages from this year’s gathering was the importance of “structural” disease of the left atrium–from high blood pressure, OSA, obesity, sedentary-ism…etc

      At this year’s Boston AF symposium in January, there was one paper on the potential benefit of yoga. In fact, this one tiny presentation tipped me towards going. (I had planned skipping the meeting this year.) The paper was a let down. It was just a rehash of the group’s previous ACC abstract. The presenter admitted that he didn’t practice yoga nor did he know anything about it.

      It’s also true that a good deal of AF has a genetic basis and many athletes get the disease. That said, however, in the real world, much of AF–especially the kind seen in hospitals–occurs as a manifestation or complication of bad lifestyle choices. Healthy living will not eliminate all AF, but I am convinced that just a tiny amount of attention from a group of specialists with power–like us electrophysiologists–could have big effects.

      1. It is easy for a layman to understand that eating crappy food can clog your arteries, and that not exercising can cause your heart muscle to weaken, but the connection between an unhealthy lifestyle and your heart’s electrical system is harder to grasp.

        1. To take just one example where poor diet and lack of optimal lifestyle (maintaining normal body weight, exercising regularly) can impact on developing AFib – is people with poor diet who don’t exercise tend to become overweight and tend to be more prone to hypertension. Longstanding hypertension increases “afterload” (= makes it more difficult for the heart to pump out blood against the higher resistance from the elevated blood pressure – which leads to thickening and stiffening of the left ventricle). This in turn makes it more difficult for the left atrium to fill (because it is harder to empty blood into a thicker and stiffer left ventricle) – which ultimately results in dilation of the left atrium – and that ultimately predisposes to development of atrial fibrillation ….

          The above process is called “diastolic dysfunction” – and it is a very common accompaniment of longstanding hypertension … So – as has been stated numerous times on this excellent blog – LIFESTYLE Changes are KEY to good health.

          P.S. I fully agree that not nearly enough MDs pay attention to the importance of lifestyle change. A big reason I suspect is that they themselves don’t “live” a healthy lifestyle. I’d just make the point that NOT ALL MDs ignore the importance of maintaining a healthy lifestyle.

      2. My husband’s electro told him on several occasions that his condition could never improve and would certainly worsen “because it gets worse with age. You can’t stop getting older, can you, [Name]?” Then how can he be months older yet in sinus rhythm (while walking daily and eating a low-fat, low-sodium diet)? The ones he saw at a Major Teaching Hospital just long enough to suffer irreversible malpractice were even more egregious, explicitly telling him that none of the conditions he then suffered could ever get better and that lifestyle changes or weight loss could not help. There is a mindset among some doctors that you’re a machine – a defective, broken machine, and if a robot or a toaster can’t naturally get better over time, neither can you. Effectively, they not only don’t push lifestyle changes, they actually discourage them. And electrophysiologists seem, from my limited sampling, to be among the worst. If only we had had access to a doctor half as sensible and honest as you are when my husband really needed it.

  4. Wonder who the “nutjob” cyclist you referred to is… I think I know because it seems you’ve mentioned this guy before!

  5. Don’t you think your observation regarding the lack of focus on “lifestyle” influences on AF by the medical community are just as applicable more broadly to many health issues, e.g., cancer? An athletic mid-40s “survivor” of AF and skin cancer, I am frustrated by the missing lifestyle guidance provided by the medical community in these and other areas and wonder if it’s unfortunately woven deeply into the structure of the industry where economic incentives are best served by after-the-fact procedures and medications.

    Thank you for publishing your honest, experience-borne views! I look forward to reading your posts.

    In regards to lifestyle changes, I would love to better understand your views on guidelines for “safe” levels of exercise. I don’t know and my EP wouldn’t say exactly but I suspect that pushing too hard on the elliptical trainer and cycling up mountains here in the Southeast elevated my heart rate too high for too long and produced my AF. I don’t have a family history of AF and I lead an otherwise healthy lifestyle. Knowing you’ve had AF and lead an otherwise healthy lifestyle, I understand you might not have it figured out either. But I want to know more about to what levels I can push my heart.

  6. Any studies about a person affected by a virus, and then the person manifests AFib, and once the virus has been eliminated, several weeks later the AFib resolves itself?

    Or do you think an AFib doctor would allow the irregularity to resolve itself without prescribing medication, cardioversion, etc?

  7. I started receiving your newsletter some while ago, and am interested in all views about prevention etc. I live in the United Kingdom.My age is 77.
    At age 57 I was diagnosed with AF. No treatment was recommended.
    Two years later, when I returned to my home town, where I was born, my doctor put me on aspitin and digoxin. (Although I had lived, since the age of 17 on a wholefood vegetarian diet, I had never paid any particular attention to exercise. I had always been active, and danced regularly each week as well as walking for miles each day.) Although , since my teens, I had preferred the ideas of ‘Nature Cure’ I had never been able to afford private treatment. We have an excellent FREE National Health Service in the UK, so, I have had anti-biotics a few times and no problems with drugs. Looking back, about 50% of the time medical treatment worked, almost by magic. On the other occasions nothing happened, but there was never any follow up or checking! (Note how many retailers follow up almost any purchases with a questionaire to ensure that their customers are happy) This has NEVER happened with my doctors. (NB)
    After a year I asked my doctor if I could stop digoxin, as I appeared to be growing breasts! She told me that I was a borderline case anyway, so stop, but continue with aspirin- to reduce stroke risk. During the ensuing years I added various supplements to my healthy diet and also was more disciplined about hydrating, which was in the news, and exercised in a more disciplined manner.
    Having recently got a wrist blood pressure monitor, this registeres AF about two thirds of the time. My heartbeat is around 70 and BP was checked over 24 hours by a consultant who stated it was NORMAL. I think, but don’t know, whether, over the years I have in fact improveved my AF. I’ve never heard or felt heartbeats or any discomfort or tiredness. In fact I would not know I had it except when doctor checks BP.
    If my AF has improved, would my doctor be able to compare my situation now with 20 years ago, when they first ECGd it? I think it’s got better, but age is supposed to see it deteriorate.
    ***********************************************************
    I can confirm that doctors rarely consider lifestyle in this or other matters. I recently had two TIAs ( 1year ago), the first possible sympton connected with the AF. Consultant immediately wanted to get me on to warfarin, statins and beta blackers. I have resisted, and keep only to the aspirin, which I’d prefer to stop (20+ years now).
    My recent study, over the last 12 months, has indicated that the various things that I do and have incorporated, reduce my stroke risk by over 150%, whereas he was saying that warfarin would reduce risk by 80%.
    My brother, a doctor, told me to expect aches and pains when I reached 60, but, at 77 I still have no regular aches and pains and am capable of doing all I want to do- walk miles daily and can dance 20 hours weekly. I also love my mini trampoline whiech I use twice most days- I like the idea of stirring up my lymph, which walking doesn’t do probably.

  8. Reading about your frustration with an apparent lack of healthy living advice, I couldn’t help but recall my own experience. Maybe it speaks to the learned experience of doctors in that relatively few patients are willing/able to make the lifestyle changes necessary to chart a new course for their health.

    Almost 2 years ago I sat in my primary care doc’s office 80 pounds lighter than when I saw him 9 months prior. Shocked by the difference in my appearance, significantly lowered blood pressure, lack of depression, and vastly improved lipid profile he asked what I had done. I told him that I cut way back on alcohol, watched my calorie intake, and started vigorously exercising regularly….to which he started laughing. When I asked why he was laughing he replied, “Well, I tell everyone to do that, but nobody ever really does”.

    For me, it took hearing the same advice for years before something clicked in my head that it was time to remove the band-aids that the medical community were giving me…..antidepressant, BP med, chol med. I wonder if people choose the easy way out because they don’t clearly see the benefits of the alternative. If a doc says, “you have XX condition and you can take this medicine to fix it or you can make these lifestyle changes to fix it”, he/she is not telling the whole story, making it easy for the patient to accept the easy way out. If the doc says, “you have XX condition and you can take this medicine to fix it or you can make lifestyle changes that will fix it, along with giving you the opportunity to participate in your first ever triathlons, go backpacking in Yosemite, go backpacking in the Peruvian Andes over 16,000 feet, do a 3 day/300 mile bike ride, go canyoneering in Utah….”, I suspect he/she might have more people choosing the latter.

    For me it’s been an unbelievable ride…both literally and figuratively.

    I love your blog….keep it going!

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