From The Desk Of Clarence Bass

“In the long run you may end up with a broken heart.” John C. Hagan, MD, Editor’s Desk, Missouri Medicine, March/April 2014

Long-Term Marathon Runners Come Full Circle

Extreme Running Linked to Heart & Artery Disease

I remember reading in Runner’s World—with great interest— about the findings of pathologist Thomas Bassler, MD. In 1977, Bassler asserted unequivocally that running marathon distance prevents coronary artery disease. As evidence, he reported that no marathoner had died of a heart attack in the preceding 10 years. He famously challenged anyone to prove him wrong. I don’t recall anyone stepping up to meet the challenge. If there was evidence to the contrary, it wasn’t widely publicized.

The wall of invulnerability began to crumble in 1984 when popular running author Jim Fixx, at age 52, died of a heart attack while on a run. Dr. George Sheehan’s death in 1993 of prostate cancer—soon after setting an age group record on the Cooper Clinic treadmill test—was another early warning. More recently, Olympic marathoner and three-time winner of the New York Marathon Alberto Salazar, 47, was technically dead for 14 minutes due to a heart attack before being revived. He was found to have extensive coronary artery disease. Additionally, The Wall Street Journal reported in March of this year (2014) that Dave McGillivray (59), 10-mile-a-day runner and race director of the Boston Marathon (at 24, he ran solo 3,452 miles across the United States) was diagnosed with coronary artery disease. In the same article, the WSJ related that Amby Burfoot (67), winner of the 1968 Boston Marathon and now editor-at-large of Runner’s World also has heart disease. “Last March I learned that I have a very high coronary calcium,” the told the Journal. “I have a condition perhaps similar to Dave McGillivray’s,” he added.

In 1994, Dr. Kenneth Cooper, father of aerobics, was perhaps the first running icon to sound the alarm—in his book Antioxidant Revolution. Cooper’s conclusion that there may be a link between persistent long distance running and disease was based on both clinical observations and research. In particular, he had become alarmed at the increased frequency of irregular heart beat found in highly conditioned runners who had been training for many years. He was also bothered by the frequency of prostate cancer—he discovered Sheehan’s cancer—among older marathoners and ultra athletes. Cooper suggested that running long distances at maximum effort might suppress the immune system and predispose to cancer. Olympic Marathon champion and several times winner of the New York Marathon Greta Waitz died relatively young of cancer.

Dr. Cooper said then—and says now—that anyone running over 15 miles per week is pursuing something “other than fitness.”

As noted in our December 2012 update (article # 347), the connection between running too fast, too far, for too many years and atrial fibrillation (a-fib) is now widely acknowledged—and the evidence of increased mortality and excessive wear-and-tear on the heart is mounting.

The benefits of exercise are beyond dispute, but it appears that too much of a good thing can erase the benefits, relegating extreme endurance athletes to the heart-health status of inactive people.

Two new studies, one in the British Medical Journal and the other in Missouri Medicine, the journal of the Missouri State Medical Association, are the latest in a growing body of research showing an association between long-term marathon running and cardiovascular disease.

The study in the British Medical Journal (February 14, 2014) compared the carotid arteries of 42 Boston Marathon qualifiers with their much-less active spouses. “We hypothesized that the runners would have a more favorable atherosclerotic risk profile,” lead author Dr. Beth A. Taylor and colleagues wrote. Regrettably, that hypothesis didn’t pan out. Similarly, the study published in the March/April 2014 issue of Missouri Medicine found that 50 men who had run at least one marathon a year for 25 years had higher levels of coronary-artery plaque than a control group of sedentary men.

Both studies showed the considerable benefits of long distance running. The authors of the BMJ study found that habitual endurance exercise improved multiple cardiovascular risk factors, including inflammation, cholesterol, triglycerides, heart rate, body weight, and body mass. Unfortunately, it “does not reduce the magnitude of carotid atherosclerosis associated with age and cardiovascular risk factors,” the authors reported. (The carotid arteries in the neck supply the brain with blood.)

Likewise, the Missouri Medicine study found that serial marathoning improved blood pressure, heart rate, body mass, lipid profile, and diabetes. Once again, however, the downside was severe. “Long-term male marathon runners may have paradoxically increased coronary artery plaque volume,” Robert S. Schwartz, MD, et al concluded. The male marathon runners, as compared to the sedentary controls, had almost double the total plaque volume—calcified and soft—in their coronary arteries.

Dr. Schwartz and colleagues captured the essence of the problem long-term marathon runners confront: “As with any potent drug, establishing the safe and effective dose range is critically important—an inadequately low dose may not confer full benefits, whereas an excessive dose may produce adverse effects that outweigh its benefits.”

Ophthalmologist John C. Hagan, MD, understands the dilemma. He lived it.

Heart of Stone

Dr. Hagan, Editor of Missouri Medicine, told his story in an article appearing with the Schwartz study. He began with a stunningly apt title: Pheidippides’ Final Words: “My feet are killing me!”  Pheidippides is credited with running the first “marathon” in 490 BC. He ran from Marathon to Sparta, and then to Athens—about 150 miles in three days—to announce that the Greeks had defeated the Persian army. “Joy to you, we won,” were is his first words. Hagan ventures that his last words were, “My feet are killing me.” Which was literally the case. He dropped dead on the spot.

Hagan, 70, has been running since about 1967. He ran more than 25 half marathons, four marathons, and two Half Ironman Triathlons. For many years, he averaged about 30-40 miles a week. “If I didn’t run at least 12 miles, I felt it was a wasted effort,” he wrote.

At age 61, he developed atrial fibrillation. “My heart served notice of overuse and abuse,” he acknowledged. He didn’t heed the warning immediately, however, because he was confident that he was doing the right thing for his heart.

His former cardiologist discouraged him from having a CT scan to determine his Coronary Artery Calcium Score (CACS), saying it wouldn’t reveal anything they didn’t already know. An unrelated change of cardiologist later produced the go-ahead—at a very reasonable walk-in cost of $50. (A perfect CACS score is zero; 100 or less is mild calcification. The higher the score the greater the heart artery plaque burden is felt to be. A score of 400 is considered extensive.)

“I took the test with the almost smug expectation of zero coronary calcium.” The result left him broken-hearted—1606.  “OMG, the proverbial heart of stone. I had more calcium in my heart arteries than most people have in their long bones.”

Hagan and his cardiologist sprang into action. After another round of heart tests proved normal (no stenting or other immediate action was needed), he went to a lipid clinic and changed his diet from good to “fabulous.” He reduced his weight from an overweight 192 to an ideal 177. His cholesterol was good but his triglycerides were borderline high. So he went on an every-other day statin and low dose aspirin regimen. (“After 40 most people should be on a statin,” he opined. “Every cardiologist I know is so why shouldn’t our patients.”)

Of primary interest to most readers, he switched to a new “heart-friendly” balanced exercise program: five to six days a week made up of walking, swimming, bicycling, and weight-lifting. No running! His workouts were less than an hour—and “never done at maximum effort.”

His message to readers: “Regular, moderate exercise is as close to a magic elixir as we are likely to discover.” But there’s a Catch-22. “Too little can kill you, too much can kill you.”

He now feels strongly that “maximum effort, endurance exercise/sports greater than one hour duration should be discouraged, especially in those over 40.”

Finally, he recommended that “most endurance athletes over 40 should have a heart CT…”

Looking back, I have followed Dr. Hagan’s counsel in two very important ways, and perhaps equally as important ignored another aspect. I also made a diet change on my own.

My Case

Arno Jensen, MD, my original doctor at the Cooper Clinic in Dallas, may have saved my life when, in 1998, he ordered a CT scan. My Coronary Artery Calcium Score (CACS) was high, not as high as Dr. Hagan, but high. What happened after that is encouraging—and I believe instructive.

Dr. Hagan and I, of course, have divergent backgrounds. While I’ve done some form of aerobic exercise practically my entire adult life, I do not consider myself an endurance athlete. I’m certainly not a marathoner; anything akin to long distance running has always been anathema to me. I wrestled in high school, but hated running laps after practice. I’m a strength athlete who does short, hard aerobic exercise. About the longest I’ve ever run for time is a mile. Rowing 2500 meters is as close as I’ve come to traditional endurance exercise; my comfort zone is 1000m or less. Finally, I’m a doctor of law.

Surprised by my calcium score—my weight was ideal and my fitness excellent, my cholesterol-to-HDL ratio, at 3.3, was my best since coming to the Cooper Clinic as were my triglycerides, which had improved from 155 to 95—Dr. Jensen ordered a thallium stress test to determine if there was any damage to my heart. The thallium test is an expanded exercise stress test. Like the treadmill test I’d had many times before, they monitor your blood pressure and ECG pattern while running you to exhaustion. The difference is they insert an IV in your arm before the test starts and then inject a small amount of thallium (a metallic element which shows up on X-ray) into your arteries during the last minute when your heart is under maximum stress. Immediately after the test an X-ray scan is taken and compared with another scan taken while your heart is at rest. The test reveals if there are areas deprived of oxygen due to reduced blood flow. By comparing the images cardiologists can pinpoint potential sites of coronary artery blockage.

"It’s all good," Dr. Pippin, a Cooper Clinic cardiologist, said, reassuringly, as he called me in to view the results on the computer monitor. Pippin said the images "do not indicate obstructive coronary artery disease or left ventricular dysfunction." Dr. Jensen called my thallium test "perfect."

That was a relief, of course, but it didn’t mean there was no concern about the calcium building up in my heart. Obviously, something bad was going on and we wanted it to stop. As explained above, a high calcium score means there is a greater risk. It’s not a sure thing, however. Dr. Jensen told me that people with zero calcium often have heart attacks and those with scores far higher than mine sometimes do fine. To address the risk, Jensen prescribed a low dose statin. Because I had few other risk factors, my coronary risk profile was still low.

I had made another change on my own, which may explain the big drop in my triglycerides. I added canola and flaxseed oil to my low fat diet. I later added fatty fish, but the addition of vegetable oil was my first experiment with omega-3 fatty acids. That combined with the statin eventually dropped my LDL cholesterol from 139 to 62 on my last visit to the Cooper Clinic in 2012.

In addition to another—and perfect—thallium test in 2005, I had a computed tomography angiograph (CTA) scan in 2007 and again in 2011. CTA is basically angiography—without the catheter. CTA combines x-ray and computer analysis. Dye is injected into the arm and X-rays are taken from different angles to create cross-sectional images, which then are assembled by powerful computer software into three-dimensional pictures of the heart and its arteries.

Nuclear cardiologist John S. Ho, MD, who conditioned his employment at the Cooper Clinic on purchase of the new CTA technology, spent about 15 minutes showing me computer images of my heart and coronary arteries from every imaginable angle. It was amazing. He showed me that my coronary arteries are “very large,” and that there is no significant blockage anywhere; the calcification is entirely in the lining of my coronary arteries. The obstruction present is “mild” at less than 20 percent. “Clinically severe lesions are generally 70-75% in severity,” Ho explained. I’m not even close.

The repeat CTA scan in 2011 showed no change. “Upon comparison with the study in 2007, there has been no significant…progression,” Ho wrote in his report. In a telephone message, he explained that there is “no evidence of soft plaque, your arteries are quite big and there is really nothing to worry about.”

So what’s to be learned here? First, a high CACS is not a death sentence. Dr. Lynn McFarlin, who replaced Dr. Jensen as my doctor, tells me that I’ve “dodged a bullet.” By doing everything I know—diet, exercise, statin—to help myself, it appears that I have stopped the coronary disease process in its tracks.

As you may have guessed, I did not follow Dr. Hagan’s advice to avoid maximum effort. To the contrary, I embraced maximum effort—brief and infrequent—with plenty of variety and time for recovery. I believe maximum effort is required for optimal results. Contrary to Dr. Hagan’s advice, I believe that’s especially true for well-conditioned and healthy individuals over 40. I do agree, however, that maximum effort of an hour or more should be discouraged, especially in those over 40. Except for the gifted few, I wouldn’t encourage it for any age.

“Use it or lose it” applies to all muscles in the body, including the most important muscle of all—the heart.

If you don’t push your limits from time to time they will slowly recede. It’s a law of nature. Nature is frugal; the body only preserves the resources necessary to meet the demands made on it—and a little more.  The limits go down with the demands.

The best evidence I can offer is my maximum heart rate, which has not fallen in over 30 years. It was 182 when I was tested the first time at the Lovelace Medical Center in Albuquerque as I approached 40. Recent tests at the Cooper Clinic showed that it’s still in that range now that I’m over 70.

I learned early on that maximum heart rate is expected to fall as you age. When I returned to Lovelace Medical Center a few years later for repeat testing, they warned me that my heart rate would probably be less than before, as predicted by the standard formula: 220 minus your age. But it wasn’t—and still isn’t. I believe that’s due to that fact that I have continually challenged my heart with maximum effort.

 This photo, taken in 1981 by Bill Reynolds, then Editor-In-Chief of Muscle & Fitness magazine, shows Clarence during his second oxygen uptake capacity test at Lovelace Medical Center in Albuquerque. He kept going for 22 minutes as the pedal resistance increased each minute.

In my opinion—remember that I’m not a doctor—all-out effort should not be off limits for most people. Importantly, I keep my all-out efforts short, with sprints or intervals lasting 30 seconds to several minutes once or twice a week. I spread the stress all over my body by using different modalities, including the Concept 2 Rower, the Concept 2 Ski Erg, the Schwinn Airdyne, the Lifecycle, and the foothills above our home. I generally work out for an hour or less (including warm up and cool down) three times a week, walking and staying active between workouts.

How you challenge your heart is up to you. Doing what you enjoy and do well works best for most people. The only prerequisites are effort and rest. Stress and rest, together they produce amazing results. Neither one works well without the other.

Again, this is my opinion; it’s what has worked for me. Whether you accept it is up to you. If you have questions or health issues, by all means check with your doctor. Always remember to start slowly and increase effort as your condition improves.

For more details and workout plans, see my books and DVDs on our Products page: http://www.cbass.com/PRODUCTS.HTM  

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