The Lure of the Monster - Dying for what You Believe In

I am haunted by my English Channel experience

There is not a day goes by that I do not think about returning, seeing if I could cheat death, even by just little bit. After spending most of my life swimming, years training she is a cruel mistress and maybe, just maybe, may take me yet. 

One recent such account is Gino Deflorian, as recounted by EC legend Kevin Murphy, 34 time EC swimmer who similarly has almost died himself. Here is the story.

Gino Deflorian has already been swimming across the English Channel for eight hours. The sun is shining, the air is clear and the water is calm and flat, but the conditions are deceptive.

He is swimming freestyle as reliably as clockwork, consistently taking 54 strokes per minute. When he lifts his head to breathe, he can vaguely make out his destination on the horizon, Cap Gris Nez, a promontory on the French coast.

Deflorian is wearing a latex swimming cap, an ordinary swimsuit and goggles. His shoulders and armpits, neck and crotch are coated with lanolin, to keep his muscles flexible and prevent chafing. According to the rules, neoprene is not allowed. If he succeeds Deflorian, 24, will be the first Swiss swimmer to swim across the Channel.

The Rowena, a blue fishing boat accompanying him on his route, is chugging along next to him at 1.6 knots. Deflorian isn't allowed to touch the boat or a person. If he does he'll be disqualified and will have to get out of the water. An inspector on board pays close attention and keeps track of times, coordinates and Deflorian's stroke rate.

The captain's son is urinating over the railing at the boat's stern, and Gerard Moerland, Deflorian's coach, is sitting on a green camping chair on the port side, observing his swimmer. He ignores the ferries, the container ships and gigantic oil tankers as he focuses on Deflorian, making sure that he doesn't start slapping the water instead of gliding through it. If that happened, it would be a sign that something is wrong.

"Am I worried? Of course. Constantly," says Moerland. He looks at his stopwatch, and then he shouts: "Captain! Food!"

Pale Lips

It's time for a boost of energy, which happens every 40 minutes. As the boat slows down, Moerland tosses Deflorian a bottle and a bag attached to a rope. The bottle is filled with Coca-Cola and the bag contains a roll with Nutella. Deflorian turns over onto his back and allows his body to drift. He can hardly get the bag open, because his fingers, wrinkled and white down to the middle joints, are shaking so badly. His lips are pale.

The English Channel is brutally cold, although on this Tuesday in late August the water temperature is 16.8 degrees Celsius (62 degrees Fahrenheit). Water conducts heat 25 times as efficiently as air. The Channel is literally sucking the life out of the swimmer.

"Gino, how do you feel?" Moerland asks.

No response.

"Gino?" 

"It's getting cold," he replies. "And my triceps hurt."

"Okay. That's what we trained for. Just keep swimming."

Deflorian forces down the last bite and starts swimming again. He's swum 25,326 strokes since 9:25 in the morning, when he began his journey on a pebble beach at the Samphire Hoe park, directly at the Eurotunnel.

Deflorian keeps swimming. Now he's up to 25,410 strokes. Standing at the helm of the Rowena is the captain, known as the pilot, who is guiding him across the Channel. "He's gradually beginning to suffer," he says. "The demons of the Channel are trying to get to him." Deflorian keeps swimming. 25,912 strokes. 

The English Channel is to long-distance swimmers what Mount Everest is to mountain climbers: the biggest legend their sport has to offer. The strait between England and France measures 33 kilometers (21 miles) at its narrowest point. It's also one of the world's busiest shipping lanes, with about 500 ships passing through it every day. Swimming across the Channel is an extreme experience, a test of will and a personal challenge.

A Purgatory

It isn't an exclusive adventure by any means. By the end of 2012, 1,341 swimmers had conquered the Channel, and more swimmers attempt the crossing each year. There are about 300 in this year's season, which lasts from June to September, but only one in five swimmers makes it. There are eight deaths on record. 

"The only thing that counts is getting there. That's the lesson the English Channel teaches you. It's a purgatory. If it were easy to make it across, it wouldn't do anything for you. When you've made it, you're a different person afterwards," says Kevin Murphy, the so-called King of the Channel, who has swum the Channel 34 times, more than any other man in history. 

Murphy, born in 1949, was a fat child who wasn't good at soccer, so he began swimming instead. A row of certificates documenting his achievements hangs in the hallway of his apartment in Dover. He has swum across Loch Lomond, the largest lake in Scotland, and he has crossed the channel between Ireland and Scotland. "But you only get to be a real hero when you've tackled the Channel. It beats everything else," says Murphy.

He has had to be rescued from the water when he lost consciousness, he has had surgery on both shoulders and he suffered a heart attack. Murphy is a wreck. He hasn't swum in seven years. "Mentally, I can't handle the loneliness in the water anymore," he says. The Channel got to him in the end. 

Those hoping to swim across the Channel must register with one of two organizations. Murphy is the honorary secretary of one of them, the Channel Swimming & Piloting Federation. To receive permission from Murphy to embark on the swim, swimmers must provide proof of having swum for six hours nonstop in water at a temperature of no more than 16 degrees Celsius. The rule was established five years ago. "We're thinking of increasing it to eight hours," says Murphy. "Because of Susan."

'Possibly a Heart Attack'

He's referring to Susan Taylor, a British woman who died in mid-July, less than two kilometers from the French mainland and after 16 hours in the Channel. Murphy was her mentor when she was at a training camp on the Mediterranean island of Mallorca in April.

"I never would have thought that she would have problems." Taylor had to vomit because she was exhausted and had swallowed too much salt water, Taylor's brother, who was on the support boat, told Murphy. She wasn't far away from the French coast and didn't want to give up. She stopped swimming freestyle and switched to breaststroke, but after 10 or 12 strokes she said that she could no longer feel her legs. "She only took two more strokes after that," says Murphy. "I suspect it was hypothermia or dehydration, possibly a heart attack."

It's been nine hours and 20 minutes, and Deflorian is still swimming, 29,538 strokes so far. It's time to eat again. Eating is the only respite for the swimmer, whose body becomes a crisis zone. The cold is like a small rodent eating its way inside. There have been swimmers whose core body temperature was a life-threatening 31 degrees Celsius when they reached their destination.

This time the crew tosses Deflorian a honey-flavored energy bar and a sports drink, which consists of 90 percent carbohydrates. He burns about 800 kilocalories an hour, the equivalent of one-and-a-half bars of milk chocolate or eight-and-a-half slices of whole grain bread. "You can't eat enough to compensate," says trainer Moerland. "You need reserves."

Body fat is a swimmer's lifesaver in the English Channel, because it insulates the body, provides buoyancy and supplies energy. For weeks, most swimmers fatten up with an agonizing diet consisting of large quantities of bacon, pasta and nuts. Women are more successful at crossing the Channel, because they typically have more body fat than men.

Deflorian is 1.85 meters (6'1") tall and weighs 92 kilograms (203 lbs.). He has only 14 percent body fat. He isn't obese, just stocky and barrel-chested. "He's shaped like a whale," says Moerland, "but he could certainly use a little more fat around his ribs. The movement should keep him warm."

Painful Stings

"Everything okay, Gino?" Moerland asks. "Can you pee?"

"Yes, but it's hard to get it out."

When the undercooled lower abdomen becomes too cramped, the swimmer has trouble urinating. Swimmers are often forced to give up because their bladders feel like they're bursting and they can no longer endure the pain. Some become seasick while swimming in waves up to one-and-a-half meters high, while others contend with painful stings from the lion's mane jellyfish.

Moerland came prepared. He has brought along acetaminophen for pain, an antihistamine, caffeine to combat fatigue and cinnarizine for dizziness and nausea.

"Come on Gino, let's go!" Moerland shouts. Deflorian keeps swimming. 29,545 strokes.

In the one minute it took him to eat, he has drifted 120 to 150 meters away from the boat. The tidal current in the English Channel can range up to six knots and can flush away a swimmer like an empty bottle.

That's the reason why no one is able to make it France in a straight line, instead following a curved route. First the high tide pushes the swimmer in a northeasterly direction, and then the ebb tide pushes him back to the southwest. Swimmers who make it across the Channel have in fact swum at least 44 kilometers.

Deflorian is swimming near the bow of the Rowena, where the pilot can see him. For the swimmer, the pilot acts as a guide dog of sorts. He decides when the swim will take place and which course to follow. 

Deflorian's pilot has been working as a fisherman for 40 years. He catches crabs, mussels and snails, but working with Channel swimmers is much more lucrative. He charges £2,300, or about €2,735, per crossing. In weeks when the currents are especially favorable, there are routinely three swimmers a day or more attempting to cross the Channel. The fisherman could never make that much money catching mussels.

Too Risky

There are 13 officially approved pilots. Some are booked four years in advance.

Deflorian has now been in the water for 10 hours and 25 minutes, still swimming at 54 strokes a minute. The sun is setting behind him, and in front of him there is a full moon above Cap Gris Nez. Seven other swimmers are in the water today. Because of restrictions imposed by the French coast guard, no more than 12 support boats are allowed to cross the Channel each day. Because the French coast guard believes that swimming across the Channel is too risky, it barred swimmers from starting the crossing on its coast 20 years ago, but it still tolerates swimmers coming from England.

Moerland is standing at the railing, waving his arms and shouting: "Come on, Gino, come on!" The pilot, glancing at the radar screen and the map on his monitor, says: "If all goes well, he'll be there in less than an hour. But if it doesn't and he hits a wall, the current will push him past the cape."

But Deflorian doesn't hit a wall, lifting one arm after the other, meter by meter. 32,940 strokes. He's as stoical in the water as he is on land.

A year ago, Moerland asked Deflorian if he was interested in swimming across the Channel. The two men know each other from their club in Uster, a town near Zürich. Moerland is from the Netherlands, a country with a long tradition of long-distance swimming. He has coached swimmers in four Olympic Games. Deflorian has been a competitive swimmer since his youth, and he's talented, "but he would never make it to the World Championships or the Olympics," says Moerland. "The English Channel is just the right thing for him."

'I'm Hungry'

"It's not about anything for me," says Deflorian. "I just want to swim from England to France."

They arrived two weeks before the planned date of the crossing. Deflorian practiced in the Dover harbor basin every day, along with a group of other swimmers: two female students from Chicago, a heart surgeon from Cape Town and a 70-year-old Japanese man from Hiroshima.

Then it became windy, with gusts of up to 6 on the Beaufort scale, and Deflorian had to wait. Besides, the Japanese man was still ahead of him. Two camera teams, one on board the Rowena and one in a helicopter, filmed his progress. He gave up after 12 hours, five kilometers from his destination, because the strong current prevented him from reaching land.

The Rowena stops 1,160 meters (3,805 feet) off Cap Gris Nez, because the water is getting too shallow. A rowboat accompanies Deflorian for the last kilometer, because he still isn't quite there. Some swimmers were so exhausted that they couldn't complete this last, short stretch of water.

It's getting dark, and Deflorian keeps swimming. "Yippie!" Moerland bellows, jumping up and down on the deck. Then Deflorian drags himself out of the water and onto the beach. When he pulls off his goggles, his eyes are set deep in their sockets. Finally, he stands on the beach and raises his fists to the sky. His mouth forms a thin line, as if paralyzed, but then he manages a smile. He's made it. After 11 hours and 6 minutes in the English Channel. And after swimming 35,100 strokes of freestyle.

Reprinted from der Spiegel

Touch the Wall Swimming Movie Screening

On the evening of Saturday August 4, 2012, 17 year-old Missy Franklin won her fourth Gold medal of the London Olympic Games when she swam the backstroke leg of the women’s 4×100 medley relay.  It was Missy’s second world record of the Olympic games; it was her 5th Olympic medal.

It was a crowning moment for swimming’s brightest new star and end of a chapter of her marvelous journey.

That Saturday was also the end of her teammate Kara Lynn Joyce’s long and productive Olympic career.  And though she finished with four Silver medals, just making it to her third Olympics was her greatest accomplishment.

The fortunes of Missy and Kara – and that of their coach, Todd Schmitz – are the stories of Touch the Wall.

Missy’s story is becoming known – an all-American teenager who, when she’s not dominating her competition in the pool can be found doing her homework, hanging out with her friends, or just having fun at whatever she’s doing.  And she possibly might just be the nicest person on the planet.

As for Kara, she finished her college career as one of the most decorated female swimmers.  She has long had the reputation as one of the sport’s hardest workers … and most respected athletes.

Somewhat unexpectedly, they both made the Olympics, and Missy had a phenomenal start to her Olympic career as she won 4 golds and a bronze.

Touch the Wall is the story of how these two amazing women and their coach got to where they are.  It’s a story of winning and losing, of commitment, and of triumph through adversity.  It’s also a story of family, of loving what you do, and having fun with the people around you.

In a world starved for heroes, Missy and Kara stand tall in Touch the Wall.

Event:             Touch the Wall movie screening

Place:              Barrington Area Library – Meeting Room

505 N. Northwest highway
Barrington, IL 60010

Dates:             Friday, January 30, at 6:30 p.m.

                       Saturday, January 31, at 9:00 a.m.

Admission:    $5 per person donation to the BAM and BSC

Hosts:            Barrington Area Masters

                       Barrington Swim Club

Recovery from an Almost fatal Cardia Arrhythmia - Manhattan Island Marathon Race from the Kayakers Perspective

The 28.5 kayaking trip around the Island of Manhattan will be both grueling and scenic and more importantly bringing awareness to Two important Causes (literally near and dear to my heart) - Cardiac Arrhythmia Prevention and Doug McConnell's ALS charity efforts.

Doug’s swim will be accompanied by an escort boat with two crew members (Susan and Cliff Wilson I believe) as well as the support of a kayak manned by his long-time training partner, Don Macdonald. 

Bob Lee and others will be biking around the Island as well all supporting the cause and friend in the quest for raising money and awareness.

Here is a short video clip of the perspective from the kayaker and support crew for Manhattan Island.

Don's Journey since the English Channel has taken a twisted path.

While starting my training for a second attempt the English Channel that was planned for this fall (2014) I had a sudden cardiac arrhythmia event, collapsed, received life saving help. I was found to have arrhythmia problems perhaps brought on by high intensity exercise, that had gone undetected perhaps for years despite years of grueling training and hours submerged in ice cold water and distances.

Well I survived and now find myself with an implanted ICD to prevent such future events. I was running, which I jokingly say was the problem, instead of swimming. "I think ICD stands for I Can't Die".

However my experience now takes me down a path relatively untraveled since only about 1% of such incidents leave survivor's. So onto the next chapter of my swimming journey just One Stroke At A Time and Advocate Health System, Cardiac Care Services.


I am hopeful to return to the pool in the near future. But until then kayaking for Doug and his cause is great. We been at his for five years and like open water swimming, you have to adapt. As Dori says...just keep swimming, swimming, swimming, or in my case kayaking, kayaking, and kayaking.




Doug's ALS Challenge:

After another long year of training, the A Long Swim Team is planning for the Manhattan Island Marathon Swim, a 28.5-mile circumnavigation of the most prominent island that makes up New York City, in June 2014.  In the unique world of marathon swimming, successfully completing swims across the English Channel, The Catalina Channel and around Manhattan Island is considered the “Triple Crown.”  If he completes the third leg of that challenge, Doug will be in a select club of fewer than 100 swimmers with that honor.

From time to time whether your getting back into shape, training on your own without routine coaching, or simply older, paying attention to technique serves two important functions. First it reduces the amount of effort you expend to propel yourself across the same distance and second it reduces and likely prevents injury from repetitive over use.

Cross training both in the gym and in the water yourself or at camps like Ned Denison's Irish total swim confusion camp can solve these challenges. But if you cant make it to Ireland simply engage with your coach or a respected swimming friend to devise a cross training activity including core, in water, out of water, cold water, wavy conditions. 

Bursae

Around every major joint are multiple bursae, which act as cushioning pads. These pads help reduce friction in the shoulder to allow movement. During musculoskeletal injuries these bursae commonly become inflamed. This inflammation is known as bursitis which is caused by either excessive rubbing or irritation that can be caused by a variety of structures (for example the rotator cuff tendons).

Many adaptations occur during an injury, most notably inflammation occurs. Lets discuss an inflamed bursae:

Bursitis

As stated, around every major joint are multiple bursae, which act as cushioning pads. Unfortunately, when a muscle is too tight or has inadequate timing, the shoulder can get “sloppy”, cause slight subluxations, and irritate the bursae. Once the bursae are enlarged, the rotator cuff tendons have less room to move and impingement can arise. This is an unfortunate combination of muscular irritation and inflammation.

Now improving bursitis depends on the clinical presentation of the swimmer. If inflammation is driving the pain, resolving inflammation is the most likely road for success. 

Here is an example of my sloppy technique after about 7 hours in Tampa Bay.

If altered movement patterns are the resulting cause of pain, then it is essential to improve these areas. In most cases, inflammation and mechanical adaptations (impaired muscle length, strength, and timing) are the drivers of pain, but pain is rarely this clear cut. This makes a combined treatment with medical professionals essential, as improving one of this areas is neglecting complete resolution and prevention. Make sure if you are addressing shoulder pain, that you assess the clinical presentation and seek complete resolution of pain, as pain will alter movement patterns, result in weakness, and impair swimming performance.

For more on shoulder pain, consider these pieces:
10 Minute Solution: Shoulder Pain
10 Minute Solution: Shoulder Pain Part II
10 Minute Solution: Shoulder Pain Part III
Shoulder Pain? Protect Your Rotator Cuff Muscles

By G. John Mullen founder of the Center of Optimal Restoration, head strength coach at Santa Clara Swim Club, creator of the Swimmer's Shoulder System, and chief editor of the Swimming Science Research Review.

Big Mac

Testing one's resilience literally returning from death!

A few days ago, sweet recovery

I finally returned to open water swimming last weekend after a tumultuous month of surprise cardiac medical activity. I am so happy given the ride I have taken recently but more so the friends from BAM and the Otter Club at Lake Zurich, my Doctor George Christy, Good Shepard Hospital and my family welcoming me back.

Since September when I sat on the shore in Dover watching my chance to attempt the English Channel fade due to bad weather, I took off some well deserved time and focused on my heath, letting my shoulders, upper back and neck recover from the last big push in training where I was routinely stroking away 35 - 38,000 yards per week during last summer.

In late September I was diagnosed with C 4, 5, 6 stenosius and one disk that is significantly compressed and two others that appear poorly aligned. We all thought swimming took its toll, or so we thought so this wasn't the real surprise.

The big surprise came after my doctor suggested I get that ubiquitous 'turning 50' stress treadmill test. Boy was I in for a surprise. First of all I hate running, actually let me rephrase, I respect greatly those who run well, I don't, I am a plugger on land. Thus, after 14 minutes on the tread mill at 20% incline running full out my heart monitor was showing the little tell-tail signs of a problem. At the same time I could not max our my heart rate which was at 148 and should have been 170 at this point. Thank god for my swimming and aerobic capacity helping out what we discovered later in a subsequent angiogram were two artery blockages the front 50% and in the back 90%. We did not immediately do the angioplasty and stenting because my doctor knew this was a surprise and and being such a great Doc conservatively pulled back to confer. I thank god for him and his counsel, wonderful bedside manner and that he kept my health and safety at the very front of all discussions.

It was during this time we all agreed that a conservative approach was to be taken prior to my angioplasty and I started taking Beta Blockers to prevent any heart damage. While I was in no danger since we had caught this very early it nonetheless slowed my heart rate further to the low 40's. Of course because I was aerobically in such good shape it seemed just fine until coming out of anesthesia from the Angiogram.

During my recovery from the Angiogram I was very comfortable but sat up quickly and proceeded to slowly pass out, speaking with the nurses calmly that I was faint. I vaguely recall as I blacked out hearing one of the nurses say something like "should I hit him" then someone said no, give the adrenaline push. a few seconds later I came around and the whole thing was surreal. I didn't know it at the time but I flat lined according to my Doc for a 8 seconds. I recall saying to my wife later that if that was what dying was like then no problem. It was extremely calm, warm and surprising relaxing. But of course it could have simply been Vagal response or something medical like this a few commented? What ever that means. Anyway, everything went well after that recovery proceeded and other than some minor drug adjustments I am fine.

Somewhere in front of my lies another scheduled date with the English Channel Sept 1-6, 2014 to be exact and the yet unknown cervical neck issue that I hope through better and more holistic training I can avoid to achieve my dream of being the 50th over 50 person in history to cross the English Channel. My coach, Marcia Cleveland and training pal Doug McConnell will get me their!

This Saturday I do my follow-up stress test which I expect to be normal, despite my hating running, and hope to return to some normal land and water training to have fun and build back endurance for perhaps a short race or two yet this fall.

Marathon Swimmers - Deciphering between cervical neck impingement and cardiac disease

The true test of ones resilience. Listen to your body and get a full stress test.

I recently took a breather from my 2011 English Channel attempt and training to let my cervical neck impingement calm down to some 'normal state' as a test to see if swimming itself, and the resulting wear and tear on my body was the cause of my symptoms - warm tingling sensations between my shoulder blades, across the outside of my shoulders and neck. 

After these symptoms calmed down, and I began to really listen to my body, something else was amiss. These sensations when I exercised even a little bit were now also in my left front chest pectoral region and sometimes dropped down to my inside left and right elbow or even to the inside palm of my hand. A burning sensation at the back of my throat from time to time seemed linked with the amount of food I ate and led me to discuss this with my doctor, who is very good and put me on a standard OTC prescription for GERD. He already had known about the neck issues and we all thought this was it. 

During my EC training I had taken heavy loads of NSAID's and then switched to Celebrex for the cervical neck impingement pain and assumed this and the intense nutritional food loading, supplements, highly concentrated carbo diet we marathon swimmers consume probably led to tearing up my stomach lining. So we went merrily along and as my annual physical came along plus turning 50 years old we decided to get a full stress test. 

WOW a big surprise was waiting for me. 

After 13 minutes on the tread mill, my aerobic capacity and conditioning would not allow my heart rate to max out (I only got up to 148 out of the prescribed 170 I recall) at the prescribed maximum so they kept going and effectively ran me into the floor. Finally giving in (thinking that Nurse Hatchet & Attila the Hun were running the machine I am a swimmer, not a runner) I stopped. 

A testament to my training, my resting heart rate after one minute was back to 72. But in those 13 plus minutes they detected a flutter and moments later saw the telltale evidence on the X ray scope that I had some cardiac event.

 Referencing my earlier blog posts on cervical neck impingement issues, I want to share my near miss and trio of symptomatic cross-references between my newly diagnosed cardiac 'walking angina' which I will undergo an angiogram procedure this Friday for complete evaluation and the earlier reported cervical neck problems (c 4-7).

What is relevant to the marathon swimming community is the overlap of symptoms between cardiac situations, GERD and cervical neck impingement's and ignoring these in favor of assuming its the training and bio-mechanical stress on your body, DON'T!.

All result in discomfort, tingling, a fuzzy warm sensations across the same area as noted above I have learned. For me personally, I would not describe this as 'pain' but then again as a marathon swimmer pain in these areas from training, age and competition masks goes with the territory.

So Friday with my health care professionals leading the way, I embark on a journey that will take me to the 'heart of the matter' no doubt testing my resilience along the way then to cervical neck repairs perhaps with an eye on returning to the English Channel and open water swimming.

The Daily News of Open Water Swimming: The Paradox Of Exercise: Don MacDonald pointed out statistics to English Channel swimmers that indicate endurance athletes who exercise for 3 hours or more have an ...

Marathon Swimming and Heart Conditions - Who would have Thunk?

Endurance athletes who exercise for three hours or more have an increased chance of dying from a cardiac arrest


Heart attack risks are greater for athletes who compete in endurance sports. I wish someone would have explained this to me before. I have recently learned that I am one of these athletes, now 50, that faces this challenge. This could be my biggest test of resilience yet. Not getting to swim the English Channel last summer due to poor weather may have just saved my life...read on and I implore you to get a full stress test (not a regular EKG) before you jump in the water.




Channelopathies



(A) Two essential elements precipitate a cardiac event in LQTS. First, a cardiac channel defect results in a 'recharging glitch' that often can be seen on the surface ECG by a prolonged QT interval. Second, a trigger is often needed (in this case, swimming) to cause the stable but prolonged recharging system to degenerate into the trademark arrhythmia of LQTS, torsades de pointes (TdP). The outcome (if the heart ever loses control), fainting, seizing or dying, depends on whether or not order is restored to the rhythm, either spontaneously or by a defibrillator. (B) The linear topologies for the three principal cardiac channels that account for two-thirds of LQTS are shown. The gene responsible for LQT1, KCNQ1 (commonly known as KVLQT1) encodes the alpha subunit of the IKs potassium channel. The gene behind LQT2, KCNH2 (commonly known as HERG) encodes the alpha subunit of the IKr potassium channel. SCN5A, responsible for LQT3, encodes the INa sodium channel. Additional heritable arrhythmia syndromes are shown.


© 2004 Nature Publishing Group Ackerman, M. J. Cardiac channelopathies: it's in the genes. Nature Medicine 10, 463-464 (2004) doi:10.1038/nm0504-463. All rights reserved


Article from Peak Performance:

About 1 in 50,000: if you run marathons or participate in other forms of exercise which last for three hours or more, that's your approximate risk of suffering an acute heart attack or sudden cardiac death during - or within 24 hours of - your effort. For every 50,000 athletes, one will be stricken during such prolonged activity(1). Running a marathon or cycling intensely for three hours is riskier than taking a commercial airline flight, even in these troubled times!

You might think we shouldn't make such a claim in a newsletter which appeals to serious competitors, including a large number of marathon runners. But at Peak Performance our job is to provide you with all the facts about your sport, not just the pretty ones.

The truth is that marathon runners, ironman triathletes and long-distance cyclists, swimmers, rowers and cross-country skiers are all in the same boat. In fact, any athlete who participates in a strenuous test of endurance lasting about three hours or more has an increased chance of dying during - and for 24 hours following - the exertion, even when the athlete's chance of a death-door knock is compared with the risk incurred by a cigarette-smoking, sedentary layabout who spends the same 24 hours drinking beer and watching TV. The reasons for this are not entirely clear, but the heightened risks of a visit from the Grim Reaper are unsettling to most athletes, especially those who exercise in the hope of improving cardiovascular and overall health.

To find out why strenuous exercise temporarily increases the risk of death, researchers at the University of Innsbruck in Austria recently studied 38 male participants in the 1999 Tyrolean Otztaler Radmarathon, a cycling race which covers 230k, with an altitude change of 5,500m. The Radmarathon is often said to be comparable in difficulty to the hardest mountain stages of the Tour de France (2).

All 38 subjects were experienced, well-trained amateur cyclists who were free of cardiovascular risk factors and without evidence of heart disease. The Austrian researchers were especially interested in monitoring their blood levels of a specific heart enzyme called cardiac troponin I, which happens to be the most sensitive and specific marker for the detection of heart-muscle death.

Cardiac troponin I values, which were essentially at zero in all athletes before the beginning of the Radmarathon (thankfully, since you don't want your heart to start dying on you just before you begin a 230k bike race!) increased in 13 (34%) of the cyclists immediately after the competition. The risk factors for elevated cardiac troponin I included: age - being young was 'bad'; race time - racing fast increased the risk, and the highest post-race cardiac troponin 1 level was detected in the athlete with the fastest Radmarathon time; pre-race training distance - the higher the overall training volume, the greater the chances of increased cardiac troponin I after the race.

Taken together, these results suggested that younger, fitter athletes, who put more stress on their hearts (via greater training volume and higher racing intensities), were the ones most likely to incur myocardial damage.

Why heart muscle cells may die during prolonged exercise

Why were cardiac troponin I concentrations up after the Austrian race? According to the researchers, many of the well-trained athletes probably experienced sub-clinical cardiac injury during the event and this was associated with the actual deaths of heart-muscle cells. The mechanism underlying such cardiac cell deaths is unknown, although one popular theory suggests that the heightened adrenaline/noradrenaline levels sometimes observed during prolonged exercise rather perversely lead to the constriction of coronary arteries, which results in localised cell death within the heart. (Adrenaline and noradrenaline - also known as epinephrine and norepinephrine - are hormones released by the adrenal glands in response to stressful situations.)

Heart-cell death during strenuous exercise? Yes, it is a bit like having a small heart attack at the same time that your heart is performing magnificently! In fact, cardiac troponin I is usually undetectable in the blood serum of healthy people but is typically found in those who have suffered a myocardial infarction (heart attack), congestive heart failure, or myocarditis (inflammation of the heart muscle). In fact, the enzyme is used predictively by heart specialists: the higher the level in a particular patient, the poorer his prognosis.

This sounds bad! But has anyone besides the Austrians uncovered evidence of heart-structure damage after strenuous exercise? Actually, yes: one study of finishers in the Hawaii Ironman Triathlon found that 9% displayed elevated cardiac troponin 1 levels and, further, that these individuals also exhibited abnormal heart wall action and function during echocardiographic analyses(3). Another investigation found cardiac-troponin increases in 11% of the finishers of an alpine cross-country marathon (4).

Is the positive post-exercise increase in cardiac troponin I really something to worry about? Were the heart cell deaths merely a small piece of the cardiac pie? Could the lost cells be replaced by regrowth of healthy heart tissue? These key questions are very difficult to answer, especially as no histological analyses of heart tissue were performed as part of these studies, and neither were echocardiograms or electrocardiograms (ECG) carried out to determine whether heart function was impaired. To play it safe, the Austrian researchers suggested that endurance athletes 'should at least undergo serial cardiovascular examinations looking for subtle evidence of myocardial dysfunction'.

The good news for endurance athletes on the cardiac front

Before you get too spooked by these findings, bear in mind that there is also some good news for endurance athletes on the cardiac front. For one thing, it's clear that regular exercise protects you from heart attacks over broad time frames; for example, over the course of a year regular exercisers will have fewer cardiac failures than their sedentary counterparts. Also, some studies have not linked extremely strenuous exercise with cardiac damage: for example, when sports medicine specialists at the University of California studied 23 ultramarathon runners who completed the 100-mile Western States Endurance Run, a rugged race through the Sierra Mountains over steep terrain and through temperature extremes, they were unable to find any race-related cardiac damage (5).

The 23 runners completed the 100-mile race in an average time of 23.5 hours, with a range of 18.9-27.1; their ages ranged from 29 to 62 (with an average of 45) and all but three were men, none with a history of heart disease. Although all of the subjects suffered massive skeletal muscle damage during the competition (as evidenced by huge increases in serum creatine kinase levels after the race), not a single runner exhibited heightened cardiac troponin levels after the extremely prolonged exertion was over.

None the less, an increasing body of evidence indicates that some heart damage can occur during extreme exercise. In the very latest study completed at Massachusetts General Hospital and the Harvard Medical School, researchers tracked 82 runners with an average age of 47 who ran the Boston Athletic Association Marathon for five consecutive years, from 1997 to 2001. These runners had no history of coronary disease, were non-smokers and averaged 25 training miles per week(6). But their cardiac troponin I levels increased roughly 6.5-fold both four and 24 hours post-race.

No one knows how long exertion related heart damage lasts

Again, we must pose the key question - is this exertion-related damage to the heart long-lasting, or does the heart recover promptly without long-term negative effects? Unfortunately, no one knows the answer to this question right now. If you are interested in running marathons, you will have to decide for yourself if the real risk associated with the race is tolerable or not - and whether the long-term perceived risk is serious enough to warrant changing your competitive activities.

Our traditional argument that prolonged endurance activity is not bad for the heart is based on evidence that marathon runners have fairly low death rates from cardiovascular disease (when you look at them away from the race itself and the 24-hour 'window' that follows it). Essentially, research indicates that well-trained endurance athletes have about 40% of their sedentary counterpart's risk of dying from a cardiac problem on a typical day (7). If strenuous exercise is really so bad for the heart, why aren't endurance athletes keeling over at higher rates?

Note, though, that this latter argument is not entirely compelling. It is possible that marathoners might have even lower frequencies of heart attacks if they gave up marathoning and focused on shorter events which are less taxing for the heart. In support of this theory, former marathon runner Dr Arthur J Siegel of McLean Hospital in Belmont, Massachusetts (one of the investigators in the study cited above) recently told Reuters Health that running a marathon is, in effect, like overdosing on a good thing. With a more moderate approach, cardiovascular risk would still be lowered, while the elevated risks associated with marathon-like events would be avoided. Add marathon efforts to the brew, and you get the general reduction in risk but with an added risk associated with the race itself (and perhaps its long preparatory runs).

If you are having second thoughts about running marathons, you should know that the previously quoted rate of one death per 50,000 marathon runners might be a bit high. For example, there is evidence that in male runners aged 30-64 who have not been diagnosed with heart disease, there is approximately one death for each 800,000 'person-hours' of running or jogging (8). This implies that if 800,000 healthy middle-aged males began running the New York City Marathon, one of them would probably die during the first hour of the event, another during the second hour and another during the third. This kind of death rate would create some bad publicity, so it is a good thing that the New York Marathon limits the number of entrants to less than 30,000 (thus trimming the incidence of death to about one every seven years). If one assumes an average finishing time of four hours, the 800,000 figure projects a death rate of one per 200,000 marathon entrants, considerably lower than the earlier estimate of one in 50,000. Incidentally, it is known that females have a much lower risk, although the relative mortality rate has not been quantified.

Expressing the 800,000 statistic in a different way, we can say that healthy, middle-aged males who run for one hour each day can expect to die while running once every 2,192 years (800,000 hours divided by 365 hours of running per year = 2,192 years). By the same token, individuals who run two hours per day should die while running about once every 1,096 years. When the risks are seen in this light, many endurance athletes will consider them acceptably low, especially as the general risk of heart disease is reduced by strenuous training.
Heart deaths are not random events

In addition, when deaths do occur, they are certainly not random providential events. Post-mortem analyses usually reveal that something was wrong with a dead athlete's heart prior to the race (no surprise there). For example, in the study which led to the death estimate of one per 50,000 marathon entrants, a total of 215,413 runners who competed in either the Marine Corps Marathon from 1976 to 1994 or the Twin Cities Marathon from 1982 to 1994 were monitored. Three of these 215,413 runners died during their races (always after the 15-mile point) and one succumbed shortly after completion of the event. Autopsies revealed that three of the runners actually had atherosclerotic coronary artery disease (narrowing of two or three key coronary vessels), even though they were symptom-free before the races. The fourth victim (also symptom-free before death) had an anatomical defect related to the left main coronary. Thus, marathon racing didn't destroy these athletes' hearts as they paced along the streets of Washington or Minneapolis but rather uncovered 'weak links' in their cardiac systems which could not stand up to several hours of strenuous, continuous exercise.

This brings us to the issue of screening: could you take a test which might reveal that your heart was vulnerable to trouble during strenuous exercise? The relevant test in this case would, of course, be an exercise stress test, during which an ECG reading is taken as you run at increasing intensities on a treadmill. These 'exams' can frequently unmask fat-filled coronary arteries.

Unfortunately, the tests do not have a very high predictive value since as many as 63% of those who 'fail' a stress test actually have completely normal cardiovascular systems(9). Furthermore, the rate of such 'false positives' among endurance athletes can be 100% (ibid), because the natural thickening of the heart in response to endurance training changes ECG readings!

This high frequency of 'wrong calls' is troubling, not only because of the inaccuracies associated with stress testing it reveals but because many of those with false positive results are then subjected to more rigorous and invasive medical procedures, including thallium stress testing (in which a dye is placed in the bloodstream during exercise) or coronary catheterisation (in which a long tube is snaked through blood vessels into the heart). These tests are expensive and not without risk; in fact, coronary catheterisations may be riskier than marathons!

None the less, about 34% of physicians who run the Boston Marathon believe that people should undergo an exercise stress test before beginning a strenuous exercise programme(10). Interestingly enough, though, only about half of these doctors actually permitted stress tests to be performed on themselves before they began training for Boston!

Stress tests carry their own risks

One reason for this 'do as I say, not as I do' attitude may be that stress tests themselves are not without risk. The risk of dying during a stress test is a matter for debate, but has been estimated at anything between 1-in-20,000(11) and 1-in-500,000 tests(12). As you can quickly calculate for yourself, if the true stress test death rate happened to be 1-in-25,000 and the true marathon death rate stayed at 1-in-50,000, and if stress testing was used to 'screen' marathon entrants, two people would be killed during stress testing for every one athlete potentially saved!
There's more! The vast majority of individuals who die during or shortly after exercise would have had completely normal stress tests, even if the tests were given the day before they died (13). Some experts believe that stress testing can only detect about 20-25% of the likely victims of sudden, exercise-related death. None the less, if you have one or more of the known risk factors for coronary disease (obesity, diabetes, cigarette smoking, high total cholesterol, low HDL-cholesterol, high blood pressure, high stress levels, or a family history of heart disease) you may want to talk to your doctor about stress testing. If you happened to be in that 20-25% group, it would be helpful to have your cardiovascular problem detected.
Distance eventers should look for signs of heart trouble

Whether or not you have risk factors for heart disease, if you compete in distance events you should monitor yourself closely for premonitory symptoms of heart trouble. The warning signs we all know about include chest discomfort or squeezing, throat tightness, and pain that radiates into the jaw or left arm. There are other signs of trouble which are less well-known, including unusual fatigue. If you are uncharacteristically tired and are confident that this is not due to an increased training load or a recent infection, don't ignore it; mention the problem to your doctor and see if you can arrange for a routine physical examination.
In addition, a sudden, unexplained drop-off in performance which is not associated with overtraining could also indicate that something is amiss with your ticker, as could the sudden onset of heart palpitations. Finally, be particularly wary of chest discomfort of any kind which appears during exercise and then disappears afterwards. Angina often does not express itself as sharp pain; typical symptoms include squeezing sensations in the chest, and feelings of pressure or chest tightness. It is possible that up to 50% of people who have heart attacks while exercising experience a fair number of small warning signals during the days or weeks leading up to the attack - so watch out! As noted US cardiologist Paul Thompson points out, 'If you think there is something wrong, there usually is, and a physician should be consulted'.


Pheidippides, one of the first endurance athletes in recorded history, dropped dead shortly after his 21-mile, 1,470-yard run from the plain of Marathon to the agora of Athens in 490 BC. True, no autopsy was performed on the Greek messenger, and his death could have been caused by dehydration or an unsettling encounter with the god Pan in the mountains north of Athens (described in some early accounts of this first 'marathon'). In addition, we don't know how fit Pheidippides was before his fateful run, which certainly would have delivered a great shock to an untrained cardiovascular system. None the less, it is certain that exertion-related deaths do occur at a low frequency, even in well-trained athletes. The paradox of exercise is that it increases your risk of dying at the same time that it reduces it.

Re Print from Peak Performance Owen Anderson


References

1. Journal of the American College of Cardiology, vol 28, pp 428-431, 1996

2. American Journal of Cardiology, vol 87, pp 369-371, 2000

3. American Journal of Cardiology, vol 83, pp 1085-1089, 1999

4. Journal of the American Medical Association, vol 282, p19, 1999

5. American Journal of Cardiology, vol 80, pp 379-380, 1997

6. American Journal of Cardiology, vol 88, pp 920-923, 2001

7. New England Journal of Medicine, vol 311, pp 874-877, 1984

8. Journal of the American Medical Association, vol 247(18), pp 2535-2538, 1982

9. New England Journal of Medicine, vol 293, pp 367-371, 1975

10. The New England Journal of Medicine, vol 301, pp 792-793, 1979

11. Chest, vol 77, pp 94-97, 1980

12. Running Research News, vol 5(6), pp 1, 6-10, November-December 1989

13. The New England Journal of Medicine, vol 321, pp 320-324, 1989