Thursday, May 10, 2012

A Public Service Announcement

Most of the time I stay away from putting personal stuff on this blog that's not clearly running-related. )In fact I would say that's my attitude toward the internet in general.) And I suppose strictly speaking what I want to talk about today is vaguely running-related. I considered for a while leaving the personal parts out, but this is the kind of post that I feel like has the potential to save a life, and if hearing my personal perspective makes it more real or motivates you to take it more seriously, then it's worth the small loss of privacy for me.


If you read running blogs or magazines or follow any kind of running-type-news, you've probably heard about the March death of ultra-runner Micah True, or "Caballo Blanco" as he was known to many. True died on a routine twelve-mile run in the New Mexico wilderness. At the time the cause of death was unknown, but on Tuesday officials announced after an autopsy that the cause of death was idiopathic cardiomyopathy. (Follow the link for more detailed explanations; the short version is that 'cardiomyopathy' refers to a type of heart disease that causes enlargement of all or part of the heart, and 'idiopathic' just means that the cause is unknown.) It doesn't sound as if True was aware of his condition.

True's is not the first high-profile running death--not by a long shot. It seems like we hear about them more and more these days, each one creating an explosion of alarmist headlines like, "Is Marathon Running Really That Safe?" and "Are You Running Yourself to Death?" and "Marathons May Cause Heart Damage" and "Beware Marathon Heart Injury." It's one of those topics that I expect major news organizations like The New York Times and CBS have a mostly-pre-written piece about sitting around that they can run on short notice the next time someone dies at a distance event. (You can kind of tell because they all reference the same statistics & quotes & studies over and over again, & just add in a couple of sentences referencing the most recent tragedy.)

For a while the increase in the number of deaths during or after marathons called into question the safety of marathon and other types of long-distance running; over the last, say, 20 years or so, though, these concerns have largely been put to rest. We now have tons of evidence that, far from causing heart damage, intense cardiovascular activity has a protective effect and actually lowers a person's risk of a cardiac event (by up to 50%!), even when risk factors like family history or obesity are present, and people who do "vigorous leisure time activities" who do have a cardiac event have a 29% lower fatality rate than those who don't (Paffenbarger et al. 1978; Sesso et al. 2000). In a study of deaths from sudden cardiac arrest in healthy people, vigorous exercisers had a 67% lower risk (Siscovick, 1984). These are just two examples of many, MANY studies that have been done; for more, I refer you to The Lore of Running by Tim Noakes, Chapter 15.

Furthermore, it's become very clear that these aren't random people dropping dead out of nowhere. Very, very occasionally we'll see a death caused by dehydration, hyperthermia, or hyponatremia, but the VAST majority of deaths during marathons & other endurance events can be traced to pre-existing heart disease or other cardiovascular conditions, meaning the person was at a much higher risk than the general population for a cardiovascular event anyway. We just hear about these deaths more, because they're more public. In that respect, it's mostly a numbers game: The popularity of long-distance running has exploded in the last few decades, and the more people participate in an activity, the more deaths will occur during that activity. It's just as true for knitting or gardening as it is for skydiving or mountain climbing.

Of course, that's not to say that people die during endurance running and gardening sessions in the same proportions. Although Siscovick found that vigorous exercisers had an overall lower risk of sudden death from cardiac arrest, those that did die suddenly were more likely to die during said vigorous exercise than not. Endurance running is a physically demanding activity, and any activity that requires your heart to beat significantly faster or even moderately faster for long periods of time does stress the cardiovascular system. (After all, that's what makes us stronger, and part of what lowers the overall risk of a cardiac event.)

But once you've been doing it for a while and gotten comfortable with the distance and the experience of running really far, it's easy to become a bit blasé about what you're actually asking your body to do and what the biological effects are. For example, in a study of healthy runners, one researcher (Neilan, et al., 2006) found mildly impaired heart function up to a month post-marathon. Not dangerously impaired, but enough to register medically and be statistically significant. A 2001 study (Siegal) found levels of inflammatory and coagulation markers typically associated only with heart attack victims that lasted for 24 hours. For all that those facts might sound a little scary, they're not that big of a deal for a healthy person who is properly trained, fueled, & hydrated. But for someone with a pre-existing cardiovascular condition, it's a different story.

The overwhelming number of people who suffer a cardiac event while running or soon after an event have such a condition. Some are aware of it & receiving treatment. But most have experienced symptoms & warning signs (frequent, inexplicable fatigue, regular chest pains, dizziness, nausea) and ignored them, and a few have what is known as silent heart disease, meaning they are fit, strong, have few or no risk factors, and never experienced symptoms.

This is where I come in. I joke sometimes about how when I started running track in high school, I sort of picked the worst possible extracurricular given my exercise-induced asthma and barrage of biomechanical issues. It turns out the truth is a little less funny.

I've had a heart murmur all my life. When I was a kid no one worried about this much because they're fairly common in children as the heart develops and usually go away on their own. Mine, on the other hand, did not go away and has gradually become more pronounced. Realistically, even in adults most heart murmurs are benign and require nothing more than a check-up every now and then to make sure there are no symptoms of anything more serious (ie, certain types of murmurs can indicate conditions that lead to cardiomyopathy), which has always been the case for me.

My case is complicated by a few things, though. First, heart disease runs in my family. In spite of being fit, active, and eating a healthy diet, my grandmother suffered from HD for years and had multiple heart attacks, one of which caused her death when she was only 60 or so. Second, high blood pressure / hypertension runs on that side of the family as well (realistically the two are probably related). My grandmother had it and so does my dad. Third, given how (reasonably) well I eat and how active I am, you might expect my blood pressure to be crazy low. Not only does it run high for a young healthy active person, it runs high for an average, sedentary, junk-food eating American.

Even though I've never had any real symptoms (beyond the occasional chest pain), all of these things taken together put me at uncomfortably high risk for heart disease / cardiovascular event. Thankfully my age, weight, general health, diet, and activity level are all on my side, but it is still something I have to think about and pay attention to. I have to monitor my blood pressure regularly and be at least somewhat careful about my diet. (This is fairly easy given how little I eat high-fat/cholesterol/junk/processed food/red meat; it's mostly the salt that's tough sometimes, especially when eating out.)

I am grateful every day that I am able to run at all, let alone run as much and as fast and, yes, even as pain-free as I am. I think about all the force my feet absorb, the crazy lacework of bones and tendons that supports and moves my body weight, the intricate rope-and-pully system of my legs, the layers of muscle that stretch and contract, the infinitely complex network of nerves that fire in exactly the right order so that I can keep doing what I do. I push my muscles and joints. I praise them when they recover quickly, chide them when they're complain-ey, exhort them give just a little more toward the end of a race, joke about the relatively minor ways that they aren't perfect. Legs get a lot of attention from runners because they're flashy and sexy, you can see when they are working hard, and you can post pictures of them on your blog to keep people from getting too bored by all the words.

If you don't have at least 1-2 pictures like this per month in your running blog, I hear the internet shuts it down. (I mock because I love.)

As much as I adore them, though, my legs are not the linchpin of this whole operation.

If I hurt my IT band, maybe I have to rest and foam roll for a couple of weeks. If I have some concerning pain in my shins, maybe I have to take a day off and sit on the couch and ice. I have the luxury of whining on the internet about what is very, very much a first world problem. Yes, having a musculo-skeletal injury is sad and irritating. But not being able to run for a while is truly the worst possible thing that can happen as a result.

If there are issues with my heart, on the other hand--chest pains, blood pressure that won't settle down, bloodwork out of whack--that is an entirely different story. I am not pouting on the internet about the fact that I can't run. I'm not gingerly testing things out in the hallway to see if it still hurts. I'm not plotting my glorious return to racing. All I'm really doing is feeling grateful that I'm not hospitalized and am still breathing, and paying very, very close attention to my doctor.

As circumstances would have it, I had a checkup on the day True's cause of death was announced. I watched my doctor's face closely as she listened to my heart, trying to read her mind and searching for any hint of what she was going to tell me. It used to be that the site of the murmur was easy to pinpoint; these days not so much. It seems to be coming from everywhere, which ups the chances that it could be something structural. In the next week or so I'll have an echocardiogram and a blood panel to look at a bunch of stuff related to hypertension & heart disease, just to make sure there is still nothing more serious going on.

She likes that I run. (Indeed, there is evidence that healthy people at higher risk tend to benefit the most from intense exercise.) I'm not sure how crazy she is about how much I run and how hard I run (if only occasionally). I know that all of these factors nudge me every so slightly in to the higher-risk pool in terms of collapsing at the end of a race from a cardiac event. Every time a doctor listens to my heart or watches an echo or reviews my latest blood panel I worry that today will be the day they say, sorry, the risk is too high now. No more running. Or less running. Or no racing all-out.

All of this is to implore you not to take your health--the really important parts of your health--for granted. People on running blogs are always going on and on about how they "listen to their bodies" and decided to take this day off or shorten that run or whatever because their legs were tired, or their ankle felt funny, or that twinge in their hip was getting worse, or what have you. That is all fine and good, but please don't mistake that for monitoring your health. It's not the same thing. I know we're prone to making stuff like that into omg DRAMA and making it sound like the most critical thing ever because at the time it can feel very dramatic and like one of the worst things that could happen in our running lives. But the fact is that it's really, really not.

If your legs are tired and you run 10 miles anyway, oh well. Even if you insist on making it worse first, your ankle will eventually get better. If you ignore the twinge in your hip, the worst thing that possibly happens is you end up not being able to run for a few months & forking over a shit ton of cash to sports medicine people & PTs. The aboslute, worst fucking thing. (I know because I did that. Spoiler alert! The world didn't end and I'm faster now than I've been in 10 years.)

If you ignore the symptoms of cardiovascular problems because they don't seem that bad or because you think you're too young / fit / active / healthy / etc. to be at risk, you can end up with *actual* problems.

So, PLEA #1:

  • If you have unexplained fatigue that goes on for days or recurs that can't be explained by lack of sleep, poor diet, overtraining, etc., see a doctor.
  • If you have chest pains severe enough to make you go "Ow!" more than a couple of times a year, see a doctor.
  • If you have any unexplained loss of consciousness, see a doctor (though I suppose in most cases you would want to do that anyway, even if you did know the explanation).
  • If you have GI symptoms that recur or go on for a while that you can't explain or resolve, see a doctor.

Other more subtle signs of cardiac trouble include inexplicable shortness of breath, fast heartbeat, weakness/dizziness, nausea, and sweating. (You can see how it's possible, sometimes, for people who are training hard to miss these less dramatic signs.)

PLEA #2: Even if you're symptom free, do not assume that just because you are young and fit and active and eat well that you are not at risk, particularly if you don't know your family medical history re: cardiovascular stuff. Yes, the odds are in your favor. But, as a doctor friend of mine likes to put it, this is one of those "low risk, ludicrous stakes" sorts of things.

If you don't go to your doctor, if you don't have things like your heart and lungs checked out and there's a problem you don't know about, there can be real consequences. Yes, the overwhelming majority of us are fine and have nothing to worry about as long as we train, fuel, and hydrate properly, but I cringe a little every time I hear about a runner dropping dead during or after a hard race from a cardiovascular event and all the friends and family are like, "But we had no idea!" Especially when the victim is a young, healthy person with no obvious risk factors. I feel like people who are taking on endurance events who are older, less active, or know they have potentially risk factors take the whole "Check in with your doctor" thing reasonably seriously. Young, healthy people with no symptoms...not so much.

No, my heart checkups are not going to fix what's wrong with me. But knowing that I have an elevated risk and having this work done semi-regularly means that if things start to move in a bad direction, my doctor is more likely to be able to catch it early and treat me, which could prevent me from developing actual HD. And that's about my long-term survival, not running.

So please make sure to listen to the really important parts of your body in addition to the flashy parts. When in doubt, get something that seems minor checked out--it's better to find out the easy way that it's nothing than the hard way that it's not. Also, please remember that feeling strong and fit is not the same thing as actually being fully healthy, and that there are aspects of your health that you can't assess on your own. If nothing else, get your doctor to check out your heart, lungs, and blood pressure once a year, just to be sure you are as fit and strong as you feel. I know it sounds trite, but it really could end up saving your life.


  • Neilan, Mousavi, Czarnecki, Kumar, Fallah-Rad, Lytwyn, Han, Francis, Walker, & Kirkpatrick. Relation of Biomarkers and Cardiac Magnetic Resonance Imaging After Marathon Running. The American Journal of Cardiology 103(10):1467-1472
  • Noakes, Tim. The Lore of Running, Chapter 15: Running and Your Health
  • Noakes, Tim. Heart disease in marathon runners: a review.
  • Paffenbarger, Wing, & Hyde. (1978) Chronic disease in former college students: XVI. Physical activity as an index of heart attack risk in college alumni. American Journal of Epidemiology 108:161–175
  • Sesso & Paffenbarger. (2000) Physical activity and coronary heart disease in men: The Harvard Alumni Study. Circulation 102:975-980
  • Siegel, Stec, Lipinska, Van Cott, Lewandrowski, Ridker, & Tofler. (2001) Effect of marathon running on inflammatory and hemostatic markers. American Journal of Cardiology 88(8):918-20, A9
  • Siscovick, Weiss, Fletcher, & Lasky. (1984) The incidence of primary cardiac arrest during vigorous exercise. New England Journal of Medicine 311:874-877


  1. I appreciate the academia here... You are a gifted writer! And thanks for adding that photo for true credibility. :)

  2. I really love this post, thank you. I'm a Bay Area runner with a heart condition and it's so easy to get blase about it - thanks for the reminder to be careful. It was also a good kick in the bum to fuel my heart better and to be smarter about what I eat. Thanks!!