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HEART Insight:
doi: 10.1097/01.HEARTI.0000368504.48160.5f
Features: Cover Story

From Michelin Man To Iron Man

Stephens, Stephanie

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Abstract

A Heart Attack At Age 28 Inspired Brian Bishop To Become Super-Fit — Slowly And Safely

Brian Bishop had always been a self-described “pretty healthy guy” — even though the six-footer had hit 288 pounds, had a spare tire around the middle and was just about as sedentary as a body could be.

On the night of August 12, 2004, Brian recalls that he “felt funny, like my body was tingly ... a floating feeling.” He thought he had the flu, took a couple of aspirins and went back to bed. He was awakened by his body shaking uncontrollably. “It felt like furnace-to-freezer within seconds.” Because his elbows and jaw were stiff, it occurred to him that he may be having a heart attack. But he was just 28 years old, so his next thought was, “Did I sleep wrong?”

He recalled that a family member in the medical profession once told him that “if you're shaking uncontrollably and you can't stop, there's probably trauma to the body somewhere” so he told his fiancée (now wife) Kara, “You'd better call 9-1-1.”

Brian lay dumbfounded and helpless in the emergency room of Lahey Clinic in Burlington, MA, when doctors told him he was, in fact, having a heart attack. A cardiac catheterization confirmed the myocardial infarction and helped the doctors determine their next course of action. His right coronary artery had a 60 percent blockage, so the doctors inserted a stent to prop it open.

Recovering in cardiac intensive care surrounded by patients two-to-three times older than he, Brian implored God to “get me out of this.” In return he vowed “I'll change my life forever.”

Now, it was up to him to fulfill his promise: “If I'm going down, I'm going down trying. I'm not going to die on the couch.”

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PROMISE KEEPER

His placid hometown of Pelham, NH, is 32 miles from Boston, where Brian works in commercial real estate. Before his heart attack, he didn't manage work-related stress — or lunch — very well. Brian would typically scarf down a foot-long submarine sandwich, cookies, corn chips and soda and get back to work as quickly as possible.

Lab tests at the hospital showed that his “bad” LDL cholesterol was high at 200 mg/dL and his “good” HDL was way too low at 18 mg/dL so Brian's doctors prescribed a statin. For his part, Brian started reading food labels and cleared his fridge and pantry of anything that was high in salt, fat or had partially hydrogenated oils, and restocked with fresh fruit and vegetables, and heart-healthy alternatives to the food he used to eat. He also downsized his lunch to a fresh turkey sandwich — no more deli meats, mayo or butter.

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Figure. February 200...
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Figure. June 2009 16...
Figure. June 2009 16...
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With his diet shaping up, it was time for Brian's body to shape up, too. Under his cardiologist's supervision, he began walking — at first, just to the mailbox and back — with his devoted Border Collie, Briggs, loping by his side with the leash tied to Brian's hand “just in case” he collapsed.

Athletes aren't built in a day, especially after a heart attack. “I was pretty exhausted,” Brian admits. But he egged himself on: “I thought, ‘Look what I just did. If I did one mile, I bet can do two!’”

Feet walked eventually became miles walked, then miles jogged and then miles run at full-tilt. As Brian proved to be a very atypical heart patient, his doctor encouraged him to “keep going,” and he can now go for a 10-mile run, covering each mile in 6 minutes, 20 seconds.

After nearly a year, Brian lost 112 pounds and began training to compete in triathlons — these endurance races require participants to swim, bike and run a course faster than their rivals.

Triathletes often compare the swimming phase to a chaotic recipe for “people soup.” Brian, who had to learn to swim before he began training for competition, remembers the nearly-paralyzing excitement and fear. “My first triathlon, I didn't know if I was going to make it. I could have drowned!”

Biking — with the right equipment — came naturally, and fed his previously undiscovered need for speed. “It's pretty invigorating to pass people at 30 miles per hour and sustain it.”

He is currently training for the 2010 Ford Ironman® World Championship in Kona, HI, on October 9th. Ironmans are particularly grueling, involving a 3.8km [2.4 miles] swim, 180km [112 miles] ride and a 42.2km [26.2 miles] run, and the Kona event is regarded as the most challenging of them all.

“Weight loss and exercise have allowed me to persevere through anything and everything I've encountered. We all have a life: it's what we decide to do with it that makes a difference,” says Brian.

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TRAINING FOR EXTREME SPORTS REQUIRES ABUNDANCE OF CAUTION

Brian had gotten his doctor's OK, and had slowly and deliberately managed his health and fitness before engaging in strenuous physical activity to ensure that he would not overtax his heart and have another heart attack. Greek messenger Pheidippides wasn't as lucky: After he reputedly ran the 26 miles from the town of Marathon to Athens in 490 B.C. to bring the news that the Persians had been routed in the Battle of Marathon, he collapsed and died after shouting, “We have won!”

Fast-forward to 2007 and the American Heart Association recommends screening athletes and others participating in organized competitive sports who are high school aged or older for unsuspected cardiovascular disease or congenital abnormalities of the heart before they join a team or begin training for a competitive athletic event.

Screenings can speak volumes, says Gary Balady, M.D., Director of Preventive Cardiology at Boston University School of Medicine. He recommends charting family history of premature death and investigation of symptoms such as shortness of breath, dizziness, chest discomfort with active fainting or near fainting, and palpitation during exertion or at rest.

“If you suspect [a potential heart problem], best test,” he says, suggesting an electrocardiogram (EKG) or echocardiogram (ECHO) among other diagnostics, when indicated. “All of us wish we [could] easily select out all ‘normals’ and ‘abnormals’ with one simple, easy, low-cost, low-risk test identifying problems, but there is no such test.”

At any age, an athletes' seemingly robust appearance and peak physical condition may mask what's going on internally. “A 22-year-old with shoulder pain who's been doing push-ups can be easy to miss,” admits Paul D. Thompson, M.D., Director of Cardiology and Director of the Athlete's Heart Program at Hartford Hospital.

AHA notes that intense athletic training and competition seem to trigger the risk for sudden cardiac death (SCD) or disease progression in susceptible athletes with underlying heart disease.

“Atherosclerotic coronary artery disease is the primary pathological finding in individuals over 40 years of age who die during physical activity, whereas inherited cardiovascular conditions are primarily responsible for such events in younger athletes,” explains Thompson.

In younger athletes, SCD is most often associated with:

▪ Hypertrophic cardiomyopathy (thickening of the heart muscle);

▪ Anomalous coronary artery (the left coronary artery, which carries oxygenated blood to the heart muscle, is connected to the pulmonary artery instead of to the aorta, so the heart muscle does not get enough oxygen); and

▪ Congenital long QT syndrome (a heart rhythm abnormality);

Other less common causes of fatalities in young athletes include:

▪ Abnormal blood clotting;

▪ Arrhythmogenic right ventricular dysplasia or cardiomyopathy (ARVD), in which the muscle layer of the heart wall on the right side is replaced by abnormal tissue that can cause a potentially lethal heart rhythm abnormality; and

▪ Cocaine use.

Athletes — young or old — should listen to their bodies and leave denial in the locker room, advises Thompson. “Pay attention and if you have unusual, funny feelings or pain, or experience a sudden decrease in performance, get yourself checked out.”

No one wants to admit they're having a heart attack, especially not super-fit athletes. Yet cardiovascular red flags are the same, no matter a person's age or activity level. Think it's a stomach ache? Gastro-intestinal discomfort can mask heart disease in anyone, he adds.

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TAKING IT TO THE NEXT LEVEL

Perhaps because people who participate in extreme sports, such as triathlons and long-distance runs, tend to be in almost super-human physical shape, deaths associated with these events — though relatively rare — are headline-grabbers.

For instance, on October 18, 2009, three visibly healthy runners, ages 65, 36 and 26, died during a half-marathon in Detroit (cardiac problems may not be to blame; the autopsies were inconclusive).

Typically, four to eight out of every one million marathon runners will die, as will 15 triathlon participants — usually during the swimming phase. 13) Again, the cause of these deaths may not be clear-cut. A 2009 Australian study found that a third of runners evaluated after the Perth marathon had increased blood levels of cardiac troponin (cTn), a “biomarker” that is indicative of heart muscle damage. 15) But troponin can also be produced by strained or injured skeletal muscles, and researchers think that it may “leak” from the heart during exercise.

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Figure. Brian came i...
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Research in the 1980s also found elevated blood levels of the enzyme creatine kinase — which is used to measure heart damage after a heart attack — in long-distance runners.

At a conference held at Stanford University in June 2009, “Athlete's Heart, Sudden Death and Hypertrophic Cardiomyopathy,” doctors agreed to disagree about screening standards and abnormal heart conditions in extreme athletes, says Balady. He adds that there was “heated discussion” on such topics as whether an athlete's heart adapts to long-term training, as other muscles do.

“The athlete's heart is bigger — even the walls get thicker, resembling hypertrophic cardiomyopathy,” notes Balady. This occurs in response to vigorous training, allowing the athlete to perform at competitive levels. The heart also beats more slowly (bradycardia), which can raise red flags during an electrocardiogram. In the hyper-fit, screening may be associated with a high number of false positives that do not necessarily indicate abnormality.

“As we develop improved technologies and screening techniques, we'll be more likely to call an abnormal heart truly abnormal and a normal heart truly normal” in such people, he says.

For instance, new research from Johns Hopkins Medical School suggests that screening programs — which also do an excellent job of raising awareness — should include both an electrocardiogram and echocardiogram to ensure that no heart problems that can cause sudden cardiac death are missed.

Barry Maron, M.D., Director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation, and a recognized expert on young athletes, cites the need for “a systematic and mandatory reporting system for these sudden deaths” and does not rule out a national screening program for noninvasive testing.

“Sports used to be simple,” Thompson concludes. Further data should elevate the discussion on pre-participation screening and ultimately “prompt a serious effort to establish a national athlete SCD registry.” HI

© 2010 American Heart Association, Inc.

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