Monday, February 1, 2016

Two Stories, Two Endings

by Larry Creswell, M.D.

Story #1
I like to tell the story of Jim Fixx. I wasn’t a fan of running until very recently, but even I recall that Fixx played a vital role in popularizing running in the 1970s. His story is particularly compelling because in his mid-30s he was overweight (240 pounds), a smoker and inactive. At age 35, he got up off the couch, took up running and became a shining example of the many benefits of a healthier lifestyle. He’s best known for his best-selling book, The Complete Book of Running.

Sadly, Fixx went for a run through the Vermont countryside on July 20, 1984, and was later found alongside the road, dead at age 52. An autopsy showed that he had severe blockage in all of his coronary arteries and almost certainly suffered a fatal heart attack or arrhythmia. It turns out that despite his long history of obesity, smoking, and a family history of heart problems, Fixx didn’t have a doctor and hadn’t had a physical examination in years.

Story #2
This is a more contemporary story, one that came to my attention just last month. It’s the story of a young athlete who wrote me an e-mail that described some right-sided chest pain whenever his heart rate exceeded 120 beats per minute or so. He had wondered if perhaps the problem was related to reflux disease of some sort, but he was worried that the discomfort only occurred with exertion... and always subsided with rest. He also shared that he was currently taking medications for both high blood pressure and high cholesterol levels.

I supported the suggestion of his athlete friends that he get checked out. He had a stress test that was abnormal, which prompted a cardiac catheterization -- a test in which dye is injected into the coronary arteries (the arteries that supply the heart itself) and motion picture x-rays are made. This test showed two blockages in the right coronary artery (see the first image below; click to blow it up). Each was treated successfully with a coronary stent (second image). He has made a good recovery after the procedure and reports that he is feeling great.

This is the story of one of us -- an avid triathlete who’s part of the Endurance Corner family. In just my short time getting to know the EC folks, this is the second story just like this. Thankfully, each of the EC stories has had a happy ending. But it really hits home.

The Problem of Coronary Artery Disease (CAD)
Both of these stories illustrate the medical problem known as coronary artery disease (CAD)-- a problem that may be the most significant chronic medical problem in the United States. More than 13 million Americans are affected and nearly one person dies every minute in this country from this condition. Importantly for the readers here, CAD is the most common cause of sudden death in athletes over the age of 40.

The heart muscle uses a tremendous amount of oxygen, especially during exercise. That oxygen is supplied by the coronary arteries -- a left and right coronary artery that carry blood flow to the heart muscle itself. These arteries are the first branches of the aorta, the large blood vessel that carries blood from the heart to the rest of the body.

We use the term CAD to refer to the progressive development of narrowing in the coronary arteries. This process, also known as atherosclerosis, begins with fatty streaks on the inside of the coronary arteries and progresses to more severe, space-occupying blockages due to the deposition of fatty materials in the walls of the blood vessels. When the arteries become narrowed to 25-50% of their original diameter, the resulting reduction in blood flow can produce symptoms. The typical symptoms are chest discomfort (angina) that occurs with exertion (or later, at rest) and/or unusual shortness of breath. In a previous column, I included these two symptoms as warning signs that should never be ignored by athletes.

Over the years, much attention has been paid to the issue of “who gets CAD?” We’ve learned that there are several risk factors that are indicators of the likelihood that an individual will have -- or will develop -- CAD. Some of these risk factors cannot be changed (such as your age), but others can be modified to reduce your chance of developing CAD in the future.

Risk Factors You Cannot Change
Risk factors for CAD that are beyond your control include:

  • Your age (CAD risk increases with age)
  • Your gender (men are more likely than women to develop CAD)
  • Your family history (those with a history of CAD in close relatives are more likely to develop CAD themselves)

Risk Factors You Can Modify
Luckily, there are several risk factors that can be modified to reduce your chances of developing CAD. These include:

  • Obesity (or even just being overweight)
  • High blood pressure
  • Smoking
  • High levels of blood cholesterol
  • Diabetes
  • Physical inactivity

I’ll bet that most of the readers here at EC are already physically active and I’ll also bet that most of the readers here are already hard at work on the other modifiable risk factors as well. A periodic visit to the doctor will help with keeping track of the blood pressure, blood cholesterol levels and the possibility of diabetes.

Diagnosis and Treatment
The second story that I shared talked a little bit about the diagnosis of CAD. This is a typical story in this regard. The treatment was also typical. For patients with mild degrees of blockage, treatment with medicines alone may be appropriate. For those with more severe, discrete blockages, either coronary stents (expandable metallic scaffolds that push the blockage aside) or heart bypass surgery may be the best treatment.

For the Athlete
From the athlete’s standpoint, the good news is that most athletes with CAD that has been treated appropriately can continue to participate in their sports. But the real opportunities for the athlete are:

  • Screening for the risk factors of CAD and modifying those which are amenable.
  • maintaining vigilance for the potential warning signs of CAD -- especially chest discomfort and unusual shortness of breath.

Larry Creswell, M.D., is a cardiac surgeon and Associate Professor of Surgery at the University of Mississippi Medical Center in Jackson, Mississippi. You can contact him at lcreswell@surgery.umsmed.edu. You can also learn about Larry in his recent Endurance Corner athlete profile.
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