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Visit the link in our 
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runningwarehouse.com today. 
Hello everyone and welcome to 

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the Doctors of Running podcast 
where we, a group of doctors in 

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physical therapy, discuss the 
art and the signs of the stuff 

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that we're putting on our feet. 
I'm Anne Hurriya Myers and today

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we have an extra special guest. 
With us we have Doctor Tamana 

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Singh. 
Doctor Singh is a clinical 

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cardiologist and Co director of 
the Sports Cardiology Center at 

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the Cleveland Clinic. 
Thank you so much, Doctor Singh,

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for joining me today. 
I'm really excited for all of 

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the knowledge that you're going 
to share with our listeners. 

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It's truly a pleasure. 
Thanks for having me. 

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Thank you. 
So just to tell you a little 

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more about Doctor Singh and her 
background, she earned her 

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medical degree from Boston 
University School of Medicine 

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and she served her residency at 
Boston Medical Center. 

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She also served a three-year 
fellowship in cardiology at 

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Icahn School of Medicine at 
Mount Sinai in New York City. 

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Then she returned to Boston to 
complete her specialty training 

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in sports cardiology with the 
Cardiovascular Performance 

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Program Fellowship at 
Massachusetts General Hospital. 

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She joined the Cleveland Clinic 
medical staff upon completion of

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that experience in June 2018, 
and she has provided cardiac 

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care for pro sports teams, 
competitive and recreational 

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athletes, and highly active 
individuals, making her the 

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perfect person for our episode 
today. 

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She has significant experience 
in cardio pulmonary exercise 

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testing, specifically in 
athletes and has participated in

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multiple pre participation 
screening events for collegiate 

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and professional athletes to 
help ensure their safe 

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participation in sports. 
And in addition to all of this, 

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she's also a runner and Doctor 
Singh is getting ready for New 

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York City Marathon in two weeks 
and that's your 7th marathon, 

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right? 
Yeah. 

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It's very exciting. 
That's awesome. 

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Yeah, you're in the home 
stretch. 

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It's taper time. 
Yes, my favorite. 

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I love Taper time. 
Yes, all the work has been done.

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Now you can recover a little bit
and gear up for the race. 

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Exactly. 
That's awesome. 

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So, Doctor Singh, please tell us
a little bit about your work as 

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a sports cardiologist. 
How you got into running and how

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marathon training has been 
going? 

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Sure. 
Yeah. 

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So I mean you kind of spelled it
all out with respect to my 

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sports cardiology background. 
So we take care of athletes 

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ranging from post US and high 
school all the way to the 

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professional level. 
Masters athletes, younger 

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athletes, recreational 
individuals and even people 

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within the cardiovascular realm 
who just want to get healthy. 

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You know, an athlete is we 
obviously have kind of 1 

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definition that a lot of us 
think about when we think 

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athlete. 
But everyone is an athlete to 

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some extent and it's really 
about incorporating a particular

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movement on a consistent basis 
and that could be how you are 

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athletic and incorporating 
fitness into your life. 

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So that's definitely one. 
Aspect of what I do. 

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So I take care of healthy 
individuals, people who have 

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cardiovascular problems to begin
with, where often times we'll 

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see people coming to our clinic,
you know, seeking a third or 

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fourth opinion, being told they 
weren't able to play or 

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participate in a sport. 
And that's where our expertise 

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is very helpful because, you 
know, my job is really to be 

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their advocate and to find a 
reason for why they can continue

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to participate safely. 
So that's kind of the cool thing

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about my field. 
I think, you know, often times 

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we have a lot of providers who 
are really nervous. 

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Usually, you know, maybe related
to their own personal biases or 

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their inexperience. 
They get nervous about taking 

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care of athletes whether they be
high stakes or not, though 

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everybody really is high stakes 
and so you know. 

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When you get nervous, you tend 
to hold back and it's very easy 

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for providers to hold their 
patient athletes back. 

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So that's where a sports 
cardiologist like me can come in

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and say, you know what, let's 
actually find some concrete 

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reasons for one, why you're able
to proceed with sport or two, 

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why we may have to actually do 
some modification. 

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So. 
So those things are really what 

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make me really grateful to, to 
do this as part of my work and 

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then in terms of running. 
So it's really interesting, you 

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know? 
I think in college everybody 

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gains kind of like the freshman 
15 or 30, and I was pretty 

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active growing up. 
I never did team sports. 

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I hated running, but I figure 
skated and in ballet and and 

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stuff like that. 
But eventually I kind of got to 

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Med school and thought I should 
probably lose a little weight. 

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I feel a little chunky and this 
body feels foreign to me. 

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So I started doing a little bit 
of running just for weight loss.

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And then when I was interviewing
for sports cardiology, when my 

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mentors told me you better be, 
make sure you bring some running

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sneakers, because everybody 
runs. 

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And I said no, no, no. 
I hate running. 

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Like I only do a couple of runs 
a couple of times a week and 

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then by the end of that year I'd
done a 10 mile or it's getting 

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ready to do a half. 
And then I went on my marathon 

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journey. 
That's amazing. 

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It's so funny how many Runners 
stories start with I Hate 

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Running and then seven marathons
later. 

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Well, I think because usually in
school running is sometimes like

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a form of punishment, you know, 
if you're late or. 

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You know, do something, I don't 
know. 

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You know, everybody's like run a
lap, run 10 laps, so, but maybe 

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there's something that as we get
older we start to look for in an

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endurance sport, I'm not sure. 
Definitely. 

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And I also think that new 
runners tend to run too hard all

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the time, which makes running 
feel awful. 

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But then as you get more into 
it, you start to figure out that

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it's actually good to run. 
Easy. 

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A lot of the time and then you 
see the benefits of both hard 

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training and easy training and 
maybe it's a little more 

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enjoyable. 
Exactly, exactly. 

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Yeah. 
So how's your New York prep been

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going? 
Ealing. 

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Good. 
Yeah. 

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I mean, this was an interesting 
training cycle. 

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It's, I joke with my coach, this
is more of like a a training 

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cycle amidst a recovery cycle. 
I I think things were going 

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pretty strong until about two 
months ago when I got a bit of a

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calf strain and a little tibial 
stress reaction. 

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But. 
I was fortunate enough to have 

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kind of like a little anti 
gravity system in my home. 

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So using that and just kind of 
trying to cross train a little 

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bit, I was able to you know 
progress my running a lot more 

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than I thought I could. 
So I think I started the month 

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of September thinking I was not 
going to be running the marathon

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and now here we are. 
So I'm running this with 

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gratitude and running this to 
really not so much be the and 

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I'll be a love. 
All of recovery is over once the

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marathon is over, but more so. 
This is just a part of the 

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recovery process. 
Let's see what I can do. 

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And you know, there will be more
marathons out there. 

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But I've only got one of two 
cabs, so let's be smart. 

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That's true, yeah. 
You know, sometimes you can 

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surprise yourself. 
I mean, there's no such thing as

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like a perfect build for any 
race. 

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So even when something when 
you're training hasn't gone to 

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plan at all, you can still 
surprise yourself on race day. 

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So good luck to you in two 
weeks. 

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I'll definitely be looking for 
you on the tracker. 

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Thank you. 
Sounds good. 

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Yeah. 
All right. 

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So let's move on to our 
subjective question. 

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So to our listeners, you know 
we're talking about 

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cardiovascular health and 
running is. 

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One of the greatest ways to 
build cardiovascular fitness and

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improve your overall health. 
But there are a lot of health 

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benefits that we get from 
running. 

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So what is the most important 
health benefit that you get from

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running? 
And Doctor Singh, I'll ask you 

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that question too. 
Why do you run? 

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You know, I think that answer 
changes the older you get and 

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the more experienced you become 
as a runner and as an athlete 

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and as a human, essentially, I 
think, you know, actually my 

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running journey. 
Began because I wanted to lose 

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weight and then it kind of went 
into, I wanted to get healthier 

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and now it's really morphed 
into, you know, how can I show 

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myself that I'm pushing past 
barriers and walls that I put up

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myself and I think seeing your 
potential and exceeding your 

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expectation. 
It doesn't have to be APR, you 

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know, It can be anything really.
Shows you how strong you are, 

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how capable you are, and it 
helps you build up mental 

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toughness. 
And that for me really 

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translated into my professional 
work and my personal 

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relationships. 
So I I go into running now more 

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so because I do know it helps me
from a health perspective, but 

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it really it challenges me as a 
human and it it helps me realize

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that there's a lot more. 
And me that I have yet to tap 

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into. 
So those are kind of the big 

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benefits I get. 
Absolutely. 

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I love that. 
I would say for me, I've been a 

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runner since I was like 4 years 
old, so running is just like a 

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part of life for me. 
And I couldn't run for a while 

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because of a knee injury when I 
was in my 20s, so I took up 

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cycling. 
But endurance exercise is just 

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as important as like. 
Eating or sleeping to me, if I 

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don't do it, I just don't feel 
right. 

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So I guess it's just good for my
overall physical and mental 

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health. 
But I similarly, I also like 

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giving myself new challenges. 
That's why I came back to 

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running after bike racing for so
many years. 

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Just having something new to 
focus on, new goals to think 

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about. 
So yeah, it's it's. 

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Never too late to improve some 
aspect of your training, yeah? 

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And there's a huge running 
community. 

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I don't, Yeah, I don't think I 
especially after I moved to 

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Cleveland, I didn't really know 
much about the running scene 

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here. 
And then I think just with 

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social media and. 
What you have in your backyard 

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running just bring so many 
people together. 

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I mean, where else can you get 
50,000 people who like to do one

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thing together and then have 
random people cheer for you? 

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So absolutely. 
That's pretty cool. 

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Yeah, it is, yeah. 
When I moved to Connecticut, I 

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didn't know anybody and I met 
most of my friends initially 

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through cycling. 
And same thing. 

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I would have never met those 
people if it wasn't for like a 

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shared love of some activity. 
I just did a half marathon 

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yesterday and it was so awesome 
just seeing all of these people 

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that I've met because of running
or cycling throughout the years.

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And yeah, community is so 
important and what a great way 

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to get a community through an 
activity like running. 

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All right, so let's move on to 
our main segment. 

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And 1st, I just want to talk 
about all of the benefits of 

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regular cardiovascular exercise.
I mean, I don't think any of our

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listeners need to be convinced 
as to why running is great, but 

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I also think that a lot of our 
listeners don't realize all of 

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the great benefits they're 
getting from the running that 

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they do. 
So could you tell us some of the

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reasons regular cardiovascular 
exercise is so good for us? 

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Oh my gosh. 
There's so many, so many 

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reasons. 
The key reasons and the key 

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health benefits that we 
typically get from consistent 

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physical activity include 
regulation of our blood sugar, 

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you know, prevention for 
diabetes, the regulation of our 

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blood pressure. 
So it helps to keep a lot of our

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00:12:03,880 --> 00:12:06,560
blood vessels in our body nice 
and pliable so that they can 

235
00:12:06,560 --> 00:12:09,840
dial it and get larger to 
accommodate greater oxygen 

236
00:12:09,840 --> 00:12:13,160
demand to our muscles when we 
need them versus vessels that 

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00:12:13,160 --> 00:12:15,640
could get really stiff with high
blood pressure over time and not

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allow for that oxygen delivery. 
It helps to control our blood 

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cholesterol. 
So cholesterol is basically what

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00:12:21,200 --> 00:12:23,680
accumulates in these in our 
blood vessels, our heart 

241
00:12:23,680 --> 00:12:26,520
vessels, our coronary arteries 
for instance, which can cause 

242
00:12:26,520 --> 00:12:29,600
heart attacks. 
And so exercise helps to control

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00:12:29,600 --> 00:12:32,840
a lot of that bad cholesterol. 
In our blood weight management, 

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00:12:32,840 --> 00:12:35,240
we kind of touched on that a 
little earlier, you know, by 

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kind of optimizing our body 
composition. 

246
00:12:37,480 --> 00:12:41,280
I hate to kind of mention weight
as a finite number as a target. 

247
00:12:41,280 --> 00:12:43,800
It's really our body comp, you 
know looking at our fat muscle 

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00:12:43,800 --> 00:12:47,160
ratios, exercise can really help
to define that for you and. 

249
00:12:47,400 --> 00:12:49,960
Especially kind of whichever 
track you're looking at with 

250
00:12:49,960 --> 00:12:51,920
respect to the type of athletics
you enjoy. 

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So those are kind of the 
majority of exercise benefits or

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00:12:55,920 --> 00:12:58,160
yeah, health benefits you get 
from exercise. 

253
00:12:58,160 --> 00:13:01,480
And interestingly, a lot of 
those in conjunction with one 

254
00:13:01,480 --> 00:13:03,800
another can reduce your 
cardiovascular risk by about 

255
00:13:03,800 --> 00:13:05,960
80%. 
So a lot of times I tell my 

256
00:13:05,960 --> 00:13:08,640
athlete patients, you know, 
cardiovascular disease is the 

257
00:13:08,640 --> 00:13:13,200
number one killer, but we can 
prevent it by almost 80% with 

258
00:13:13,200 --> 00:13:16,480
just lifestyle and behavior 
modification optimization and 

259
00:13:16,720 --> 00:13:18,760
we've already. 
Talked a lot about some of those

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kind of psychological benefits 
in addition to the physical 

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00:13:21,560 --> 00:13:24,400
benefits we gain. 
So this is kind of like a win 

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00:13:24,400 --> 00:13:27,800
win situation. 80%, that's 
amazing it. 

263
00:13:27,960 --> 00:13:31,480
You know, a lot of people say if
exercise were a pill it would be

264
00:13:31,480 --> 00:13:33,680
a, you know, multi billion 
dollar drug. 

265
00:13:34,120 --> 00:13:38,320
But I think it's becoming more 
common for doctors and of course

266
00:13:38,320 --> 00:13:41,160
physical therapists. 
It's the main part of our jobs. 

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00:13:41,160 --> 00:13:46,240
We prescribe physical activity 
to people and the results can 

268
00:13:46,240 --> 00:13:48,440
be. 
Just as good, if not better, 

269
00:13:48,440 --> 00:13:51,280
than some of the drugs that 
doctors could prescribe. 

270
00:13:51,680 --> 00:13:53,040
Oh yeah. 
I mean, it's not a big 

271
00:13:53,040 --> 00:13:55,680
necessarily money maker in the 
health industry, right? 

272
00:13:55,680 --> 00:13:58,920
Treatments and drugs and 
procedures tend to make a lot of

273
00:13:58,920 --> 00:14:02,920
the money, but prevention is the
most cost saving thing that we 

274
00:14:02,920 --> 00:14:05,800
can do and it's probably the 
most economical, most 

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00:14:05,800 --> 00:14:09,520
environmentally friendly. 
You know, we can reduce our 

276
00:14:09,520 --> 00:14:13,280
impact and improve kind of our 
human value. 

277
00:14:13,720 --> 00:14:17,080
With something that's just as 
simple as a consistent movement.

278
00:14:17,360 --> 00:14:20,520
So there's like I said, there's 
there's no harm to to trying and

279
00:14:20,520 --> 00:14:22,080
maintaining the habit. 
Definitely. 

280
00:14:22,480 --> 00:14:26,080
So what are the current physical
activity recommendations for 

281
00:14:26,080 --> 00:14:27,760
adults? 
How many minutes per week? 

282
00:14:27,760 --> 00:14:30,320
And what type of exercise are we
talking about? 

283
00:14:30,640 --> 00:14:33,520
So I typically cite the American
Heart Association guidelines, 

284
00:14:33,520 --> 00:14:37,480
which is based upon essentially 
United States Physical Activity 

285
00:14:37,800 --> 00:14:41,440
guidelines that are are. 
Evidence space and I think from 

286
00:14:41,440 --> 00:14:45,360
2018. 
So the two styles of exercise 

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00:14:45,360 --> 00:14:48,560
that help us gauge the amount of
time per week are basically 

288
00:14:48,560 --> 00:14:51,200
moderate intensity or 
conversational pace exercise and

289
00:14:51,200 --> 00:14:54,760
vigorous intensity or high 
intensity kind of, you know, 

290
00:14:54,760 --> 00:14:57,200
you're speaking a couple of 
words at a time. 

291
00:14:57,560 --> 00:14:59,520
Huffing and puffing. 
A little bit type of exercise. 

292
00:14:59,520 --> 00:15:03,200
So the AJ recommends about 150 
minutes of moderate intensity 

293
00:15:03,200 --> 00:15:06,440
exercise per week and 75 minutes
of vigorous and you could do a 

294
00:15:06,440 --> 00:15:08,440
combination. 
You could do one or the other. 

295
00:15:08,520 --> 00:15:10,520
In all honesty, it's really 
whatever you enjoy doing. 

296
00:15:10,880 --> 00:15:13,920
And that's that's so achievable.
It's what I think for a lot of 

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00:15:13,920 --> 00:15:16,400
our listeners that will sound on
the low side. 

298
00:15:17,240 --> 00:15:20,680
I know that I did a nine and a 
half hour training week last 

299
00:15:20,680 --> 00:15:26,400
week, so I met that goal from 
the AJ, but it's not a lot. 

300
00:15:26,400 --> 00:15:30,960
You don't have to. 
Do so much, it doesn't take up a

301
00:15:31,360 --> 00:15:35,120
whole chunk of your day. 
You can get it in in smaller 

302
00:15:35,120 --> 00:15:37,720
chunks, right? 
Like the recommendation isn't 

303
00:15:37,720 --> 00:15:41,720
that it has to be continuous, it
could be 310 minute walks 

304
00:15:41,720 --> 00:15:43,040
throughout the day. 
Exactly. 

305
00:15:43,040 --> 00:15:47,040
I mean at this point I think you
know we're we're saying anything

306
00:15:47,040 --> 00:15:48,880
is better than nothing. 
Right. 

307
00:15:48,880 --> 00:15:52,400
And you know, people are very 
busy, but you do have those 10 

308
00:15:52,400 --> 00:15:55,600
minutes in a day to get up from 
your desk and to go out and walk

309
00:15:55,600 --> 00:15:58,640
or use part of your lunch break 
to do that or use it. 

310
00:15:58,640 --> 00:16:01,240
You know, when your kids are 
bugging you at home and you're 

311
00:16:01,240 --> 00:16:04,120
like, you guys go to bed, I need
to go outside for 15 minutes and

312
00:16:04,120 --> 00:16:07,600
do something for me. 
So movement is movement, however

313
00:16:07,600 --> 00:16:09,040
you do it, whichever way you do 
it. 

314
00:16:09,040 --> 00:16:10,880
But it will add up. 
Absolutely. 

315
00:16:11,320 --> 00:16:14,800
So then thinking about people on
the other end of the spectrum. 

316
00:16:15,680 --> 00:16:18,880
Has research found that there is
an upper limit to the volume of 

317
00:16:18,880 --> 00:16:23,760
beneficial exercise? 
So interestingly, this is a 

318
00:16:23,760 --> 00:16:26,360
great question actually just 
because we know about a lot of 

319
00:16:26,360 --> 00:16:29,160
those cardiovascular benefits 
and health benefits we get from 

320
00:16:29,840 --> 00:16:32,640
exercise dose. 
So that integrates intensity and

321
00:16:32,640 --> 00:16:35,360
volume and duration. 
And there's this extreme 

322
00:16:35,360 --> 00:16:38,600
exercise hypothesis that exists 
that shows this kind of 

323
00:16:38,600 --> 00:16:43,080
curvilinear decrease, meaning as
exercise dose increases or 

324
00:16:43,080 --> 00:16:48,000
health benefits. 
Or or health risk, I should say 

325
00:16:48,000 --> 00:16:50,480
decline. 
So we see this decline until a 

326
00:16:50,480 --> 00:16:52,760
certain point. 
That point has yet to be 

327
00:16:52,760 --> 00:16:55,360
defined, but there are some 
studies that suggest that 

328
00:16:55,360 --> 00:16:59,080
perhaps with extreme exercise, 
so beyond a particular exercise 

329
00:16:59,080 --> 00:17:00,880
dose those health benefits are 
lost. 

330
00:17:01,360 --> 00:17:04,880
So the types of studies that 
we're looking at that might show

331
00:17:04,880 --> 00:17:08,599
with extreme, extreme exercise, 
we see some. 

332
00:17:09,079 --> 00:17:12,440
Loss of health benefit are 
really epidemiological studies, 

333
00:17:12,720 --> 00:17:17,480
so they're not kind of tried and
true prospectives types of 

334
00:17:17,480 --> 00:17:20,280
studies. 
There's no actual number that I 

335
00:17:20,280 --> 00:17:23,560
could define saying, oh, beyond 
this many hours per week or this

336
00:17:23,560 --> 00:17:25,839
many hours in your lifetime, 
your risk goes up. 

337
00:17:26,119 --> 00:17:28,480
But we do know that there are 
some cardiovascular 

338
00:17:28,480 --> 00:17:32,560
manifestations, whether they be 
actually harmful or not harmful 

339
00:17:32,560 --> 00:17:35,520
can. 
Exists particularly when we see 

340
00:17:35,520 --> 00:17:37,000
decades and decades of 
endurance. 

341
00:17:37,600 --> 00:17:42,240
So we really don't know what 
like the optimal dose is, and we

342
00:17:42,240 --> 00:17:46,680
don't really know what the upper
limit is of cardiovascular 

343
00:17:46,680 --> 00:17:48,200
training over a lifetime. 
No. 

344
00:17:48,200 --> 00:17:50,440
And if you think about it, the 
majority of us are probably not 

345
00:17:50,440 --> 00:17:53,320
even going to get close to that 
extreme number. 

346
00:17:53,880 --> 00:17:55,840
I think the people who are 
probably. 

347
00:17:56,760 --> 00:18:00,120
Maybe at that Nader or at that 
point where we're starting to 

348
00:18:00,120 --> 00:18:03,200
see a little bit of loss of 
health benefit might be, you 

349
00:18:03,200 --> 00:18:06,040
know, endurance athletes who are
really working at high, high 

350
00:18:06,040 --> 00:18:08,880
intensities for decade upon 
decade upon decade. 

351
00:18:09,160 --> 00:18:11,800
So maybe people who started in 
their 20s and are continuing in 

352
00:18:11,800 --> 00:18:14,720
their 50s or 60s. 
But again, that's relatively 

353
00:18:14,720 --> 00:18:18,520
anecdotal and we don't have any 
large, you know, database 

354
00:18:19,240 --> 00:18:22,240
evidence to support that. 
But when we're looking at the 

355
00:18:22,760 --> 00:18:25,040
changes that we see from a 
cardiovascular perspective, it 

356
00:18:25,040 --> 00:18:26,640
typically tends to be in this 
higher. 

357
00:18:26,760 --> 00:18:29,480
Intensity higher exercise dose 
category. 

358
00:18:29,840 --> 00:18:33,360
And we'll get more into what 
because I know a lot of people 

359
00:18:33,360 --> 00:18:36,400
who would fall into that 
category, including myself. 

360
00:18:36,680 --> 00:18:39,840
So and we'll get a little more 
into what should people like 

361
00:18:39,840 --> 00:18:45,160
that do regarding maybe pre 
activity screening or figuring 

362
00:18:45,160 --> 00:18:48,320
out their individual risk a 
little bit later in the podcast.

363
00:18:49,400 --> 00:18:53,720
But next I wanted to talk to you
about the cardiac changes that 

364
00:18:53,720 --> 00:18:57,040
occur in endurance athletes. 
Because we do know that there 

365
00:18:57,040 --> 00:19:00,920
are there's a constellation of 
changes that are typically seen 

366
00:19:00,920 --> 00:19:05,960
in people who do endurance type 
training over a long period of 

367
00:19:05,960 --> 00:19:08,160
time. 
And some of them are the changes

368
00:19:08,160 --> 00:19:11,360
are positive, but others may 
potentially lead to problems 

369
00:19:11,360 --> 00:19:13,520
down the road. 
So could you first tell our 

370
00:19:13,520 --> 00:19:16,920
listeners what the normal, what 
are the normal cardiac changes 

371
00:19:16,920 --> 00:19:18,800
in endurance athletes? 
Sure. 

372
00:19:18,920 --> 00:19:21,960
So I think the first thing to 
remember is that exercise in 

373
00:19:21,960 --> 00:19:24,720
itself is going to be some form 
of stress. 

374
00:19:25,000 --> 00:19:28,560
So whether you're healthy or not
healthy, it can trigger kind of 

375
00:19:28,560 --> 00:19:30,800
a little bit of a stress 
response with respect to your 

376
00:19:30,800 --> 00:19:33,880
body that is transient, that 
lasts for a couple of hours and 

377
00:19:33,880 --> 00:19:37,960
it goes away over time. 
With exercise, we do see changes

378
00:19:37,960 --> 00:19:41,160
that are related to exercise 
called exercise induced cardiac 

379
00:19:41,160 --> 00:19:44,200
remodeling and that typically is
going to be dependent upon the 

380
00:19:44,200 --> 00:19:48,120
type of sport you play nor data 
and our kind of initial. 

381
00:19:48,560 --> 00:19:51,000
Guidelines looking at 
cardiovascular abnormalities and

382
00:19:51,000 --> 00:19:54,360
competitive athletes tried to 
demarcate the cardiovascular 

383
00:19:54,360 --> 00:19:59,920
changes that we see in chamber 
size and in chamber function, 

384
00:19:59,920 --> 00:20:01,240
tried to make it a bit black and
white. 

385
00:20:01,240 --> 00:20:04,360
But we're realizing a lot of 
sports fall into two or a 

386
00:20:04,360 --> 00:20:06,400
combination of the two 
categories, whether they be 

387
00:20:06,400 --> 00:20:10,200
endurance or whether they be 
more of like the weightlifting, 

388
00:20:10,200 --> 00:20:13,400
powerlifting type of a category.
With endurance sport, we 

389
00:20:13,400 --> 00:20:17,720
typically anticipate that the 
heart size is going to get a 

390
00:20:17,720 --> 00:20:21,240
little larger, and usually all 
four chambers in the heart just 

391
00:20:21,240 --> 00:20:23,280
get a little larger proportional
to one another. 

392
00:20:23,320 --> 00:20:25,880
One doesn't get bigger than the 
other chamber. 

393
00:20:25,880 --> 00:20:29,280
That would be an abnormality and
the relaxation patterns of the 

394
00:20:29,280 --> 00:20:33,400
heart also maintain are 
retained. 

395
00:20:34,600 --> 00:20:38,240
So why does that happen? 
Well, with endurance activity we

396
00:20:38,240 --> 00:20:40,760
require higher stroke volume, 
higher blood volume to flow 

397
00:20:40,760 --> 00:20:44,320
through our cardiovascular 
system to provide the oxygen 

398
00:20:44,320 --> 00:20:45,640
that we need to go to our 
muscles. 

399
00:20:45,640 --> 00:20:48,240
The demand is just higher. 
So to accommodate for greater 

400
00:20:48,240 --> 00:20:49,280
volume, what's the heart going 
to do? 

401
00:20:49,280 --> 00:20:51,080
It's going to get a little 
bigger. 

402
00:20:51,160 --> 00:20:55,560
Comparing that to people who are
power lifters or weight lifters,

403
00:20:55,560 --> 00:20:58,000
you know, they have to deal with
a higher pressure load on the 

404
00:20:58,000 --> 00:21:00,680
heart and the heart is a muscle 
just like a bicep. 

405
00:21:00,680 --> 00:21:03,760
So in order to accommodate that 
higher pressure or quote UN 

406
00:21:03,760 --> 00:21:06,120
quote higher weight that perhaps
a bicep would see, they would 

407
00:21:06,120 --> 00:21:08,480
get a little thicker. 
So those are kind of two of the 

408
00:21:08,480 --> 00:21:11,280
predominant camps. 
We see either increase chamber 

409
00:21:11,280 --> 00:21:15,280
size or increase wall thickness 
for our runners, our cyclists 

410
00:21:15,280 --> 00:21:17,760
nor skiers. 
We're typically thinking more 

411
00:21:17,760 --> 00:21:21,040
along the camps of probably some
little bit of enlargement in the

412
00:21:21,040 --> 00:21:24,400
heart with no compromise and 
function or relaxation. 

413
00:21:24,480 --> 00:21:30,360
That's normal in situations 
where we see abnormalities in 

414
00:21:30,360 --> 00:21:32,560
chamber size. 
So some disproportionate 

415
00:21:32,560 --> 00:21:35,440
increase where we see 
dysfunction and contractility 

416
00:21:35,440 --> 00:21:38,480
and relaxation that would all be
abnormal and that would warrant 

417
00:21:38,480 --> 00:21:40,000
further investigation. 
OK. 

418
00:21:41,520 --> 00:21:46,120
Let's say a runner who's in 
their 40s has a pre op EKG. 

419
00:21:46,840 --> 00:21:51,080
That EKG might find some 
abnormalities that would be 

420
00:21:51,080 --> 00:21:54,760
considered normal due to their 
endurance training, but aren't 

421
00:21:54,760 --> 00:21:57,200
dangerous. 
What would a couple of those 

422
00:21:57,200 --> 00:21:59,920
things be? 
Yeah, so we actually have our 

423
00:21:59,920 --> 00:22:03,400
own criteria, EKG criteria for 
athletes just because as you had

424
00:22:03,400 --> 00:22:05,320
mentioned, there are certain 
things that a sedentary 

425
00:22:05,320 --> 00:22:09,960
individuals are abnormal and 
require additional evaluation 

426
00:22:09,960 --> 00:22:12,000
versus an athletes. 
There are certain things that 

427
00:22:12,000 --> 00:22:15,120
could be seem to be abnormal but
are actually normal. 

428
00:22:15,360 --> 00:22:20,280
So in some situations, sometimes
we see some variation in certain

429
00:22:20,280 --> 00:22:24,280
segments of the EKG that can be 
normal in specific populations 

430
00:22:24,280 --> 00:22:26,880
of our athletes versus our 
sedentary individuals. 

431
00:22:27,640 --> 00:22:31,440
Sometimes we can see some 
prolongation in specific 

432
00:22:31,440 --> 00:22:35,320
intervals of the EKG, which may 
be normal for athletes and not 

433
00:22:35,320 --> 00:22:37,720
normal for sedentary 
individuals. 

434
00:22:38,640 --> 00:22:41,440
Ek GS are an excellent way to 
look at the electricity of the 

435
00:22:41,440 --> 00:22:44,880
heart. 
They're not 100% diagnostic way 

436
00:22:44,880 --> 00:22:48,240
to evaluate the size of the 
heart, but there are certain 

437
00:22:48,240 --> 00:22:52,200
variations in the in the 
waveforms that can be suggestive

438
00:22:52,200 --> 00:22:56,200
of perhaps chamber enlargement. 
So those findings in isolation 

439
00:22:56,200 --> 00:23:00,560
may not require additional work 
up in athletes, but would and 

440
00:23:00,560 --> 00:23:03,560
sanitary individuals. 
So the criteria, I mean there's 

441
00:23:03,560 --> 00:23:06,840
so many different little 
criteria that it could be a 

442
00:23:06,840 --> 00:23:09,000
little overwhelming. 
But what I would say is if 

443
00:23:09,000 --> 00:23:11,640
you're an athlete, you're 
getting an EKG done. 

444
00:23:11,960 --> 00:23:14,880
Remember that the EKG done is 
typically read first by the 

445
00:23:14,880 --> 00:23:17,600
computer, and then you really 
need to have a sports 

446
00:23:17,600 --> 00:23:20,920
cardiologist take a look at it 
to be able to differentiate 

447
00:23:20,920 --> 00:23:25,000
between what would be normal for
you and what would not be normal

448
00:23:25,000 --> 00:23:28,640
for you, because there are 
certainly EKG findings that are 

449
00:23:28,640 --> 00:23:31,800
pathologic in any way. 
So would that just be that 

450
00:23:31,800 --> 00:23:34,360
athlete? 
When they go for that pre op, 

451
00:23:34,360 --> 00:23:37,680
make sure that they tell the 
provider, hey, I'm a marathon 

452
00:23:37,680 --> 00:23:40,720
runner. 
Make sure that whoever's reading

453
00:23:40,720 --> 00:23:43,240
my EKG knows that. 
How do they make sure that they 

454
00:23:43,240 --> 00:23:47,080
don't get a call from their 
surgeon saying, oh, we can't do 

455
00:23:47,080 --> 00:23:50,200
surgery because you've got some 
EKG issues? 

456
00:23:50,200 --> 00:23:52,360
Yeah, I mean, the most common 
thing is usually like a low 

457
00:23:52,360 --> 00:23:55,000
heart rate, You know, someone's 
heart rates in the 30s or 40s 

458
00:23:55,000 --> 00:23:59,200
and then the EKG is severe, 
bradycardia abnormal. 

459
00:23:59,720 --> 00:24:00,960
But that's really normal for 
you. 

460
00:24:01,560 --> 00:24:05,240
So sports cardiologists, 
unfortunately, we're a small 

461
00:24:05,240 --> 00:24:07,080
community, so we're not 
everywhere. 

462
00:24:07,120 --> 00:24:09,600
I still think telling your 
provider, hey, you know what, 

463
00:24:09,600 --> 00:24:12,280
I'm an athlete. 
I participate in exports. 

464
00:24:12,480 --> 00:24:16,000
I just want to let you know. 
I even have a copy of my prior 

465
00:24:16,000 --> 00:24:19,320
EKG that I've done just to show 
you what my normal is. 

466
00:24:19,720 --> 00:24:21,240
Think of an EKG as your 
footprint. 

467
00:24:21,400 --> 00:24:23,000
I think all of that provides 
context. 

468
00:24:23,000 --> 00:24:26,400
So if you do have a heart rate 
of 35 and they look at you and 

469
00:24:26,400 --> 00:24:29,560
you're like I've got my running 
sneaks on, I'm going for a run 

470
00:24:29,560 --> 00:24:32,560
after this, no, they're not 
going to say Oh no, there's some

471
00:24:32,560 --> 00:24:34,760
abnormality here. 
They're going to actually say 

472
00:24:34,760 --> 00:24:38,480
no, this is actually your 
normal, so don't be alarmed. 

473
00:24:38,840 --> 00:24:42,160
Provide as much context as you 
can, But also bear in mind that 

474
00:24:42,920 --> 00:24:45,640
you may not have access to 
sports cardiologist where you 

475
00:24:45,640 --> 00:24:48,440
are and if you don't, that's 
where you can you know, usually 

476
00:24:48,440 --> 00:24:50,560
reach out to providers like me 
and we can try to be of 

477
00:24:50,560 --> 00:24:52,400
assistance. 
Yes, and I'm definitely going to

478
00:24:52,400 --> 00:24:54,960
ask you about that later, 
because there are so few of you 

479
00:24:55,440 --> 00:25:00,280
and it's hard for people to find
someone who's actually 

480
00:25:00,280 --> 00:25:04,280
knowledgeable and experienced 
with athletes and to get the 

481
00:25:04,280 --> 00:25:07,360
right answers about their 
specific problems. 

482
00:25:08,360 --> 00:25:11,760
I wanted to ask you a question 
that we got from a listener. 

483
00:25:12,280 --> 00:25:16,720
This is from Mel Joy W And 
regarding, you know, we were 

484
00:25:16,720 --> 00:25:19,440
just talking about what the 
normal cardiac changes are in 

485
00:25:19,440 --> 00:25:22,240
endurance athletes, but there 
are others that aren't 

486
00:25:22,240 --> 00:25:24,600
considered normal even if you 
are an athlete. 

487
00:25:24,920 --> 00:25:28,800
So her question is his or her 
question is, can years of 

488
00:25:28,800 --> 00:25:31,200
endurance training cause long 
term damage? 

489
00:25:31,560 --> 00:25:36,200
And could you tell us what some 
of those abnormal findings are 

490
00:25:36,200 --> 00:25:38,240
in endurance athletes? 
Sure. 

491
00:25:38,240 --> 00:25:40,320
Yeah. 
So we talked a lot about kind of

492
00:25:40,400 --> 00:25:42,560
the normal exercise induced 
cardiac remodeling. 

493
00:25:42,560 --> 00:25:45,440
But there are you know four or 
five things that we have seen 

494
00:25:45,720 --> 00:25:48,640
that could be chronic changes 
from a cardiovascular 

495
00:25:48,640 --> 00:25:52,000
perspective that may or not, may
or may not be harmful. 

496
00:25:52,280 --> 00:25:55,280
And so the four that I typically
think of are increased coronary 

497
00:25:55,280 --> 00:25:58,960
artery calcification, so 
calcified deposits within the 

498
00:25:58,960 --> 00:26:02,000
heart vessels. 
There is also, you know, could 

499
00:26:02,000 --> 00:26:04,520
there be an increased risk of 
sudden cardiac arrest or death, 

500
00:26:05,320 --> 00:26:08,400
increased risk of perhaps 
fibrosis or kind of tough 

501
00:26:08,400 --> 00:26:12,040
tissue, scar tissue within the 
heart muscle or increased risk 

502
00:26:12,120 --> 00:26:16,000
of a very common heart 
arrhythmia, atrial fibrillation.

503
00:26:16,000 --> 00:26:18,440
We typically think of, you know,
older individuals being at 

504
00:26:18,440 --> 00:26:20,520
greatest risk for this, but we 
definitely do see it in 

505
00:26:20,520 --> 00:26:22,840
athletes. 
And the big question that comes 

506
00:26:22,840 --> 00:26:25,520
up are are these chronic 
changes? 

507
00:26:25,800 --> 00:26:28,600
Are these things that should 
make me take pause, make me stop

508
00:26:28,600 --> 00:26:30,560
exercising? 
Are these things that are going 

509
00:26:30,560 --> 00:26:36,200
to impact my mortality? 
Are these things going to make 

510
00:26:36,200 --> 00:26:38,840
me live a life that could have 
been healthier if I pulled back 

511
00:26:38,840 --> 00:26:42,080
on the amount of exercise I do? 
And the evidence that we have so

512
00:26:42,080 --> 00:26:46,960
far suggests that there's really
no reason to stop exercise, so 

513
00:26:47,160 --> 00:26:49,000
we can kind of break it down 1 
by 1. 

514
00:26:49,000 --> 00:26:52,400
So you know, for instance, 
coronary artery calcification, 

515
00:26:52,400 --> 00:26:56,280
what does that mean? 
So I mentioned that in our heart

516
00:26:56,280 --> 00:27:00,720
vessels, we can accumulate 
plaque cholesterol deposition 

517
00:27:01,120 --> 00:27:03,760
and that deposition can be kind 
of soft squishy plaque or 

518
00:27:03,760 --> 00:27:07,360
sometimes calcified plaque. 
But that plaque burden is 

519
00:27:07,360 --> 00:27:11,040
inflammatory, it's atherogenic, 
it's heart disease. 

520
00:27:11,320 --> 00:27:14,760
What we're finding in endurance 
athletes is that they tend to 

521
00:27:14,760 --> 00:27:18,960
have higher amounts of coronary 
artery calcification, but they 

522
00:27:18,960 --> 00:27:21,680
don't have a lot of that soft, 
squishy, sticky cholesterol 

523
00:27:21,680 --> 00:27:24,360
deposit plaque. 
And the hypothesis is that 

524
00:27:24,360 --> 00:27:28,600
perhaps that calcified deposit 
is not inflammatory at all, but 

525
00:27:28,600 --> 00:27:31,440
it could just be related to the 
mechanical stress of blood flow.

526
00:27:31,680 --> 00:27:34,360
And that again, is a hypothesis.
And there's actually been 

527
00:27:34,360 --> 00:27:37,040
studies about this. 
And there was one study in 

528
00:27:37,040 --> 00:27:41,160
particular in particular that 
showed athletes did have higher 

529
00:27:41,160 --> 00:27:44,560
burdens of coronary artery 
calcification, but those with 

530
00:27:44,560 --> 00:27:47,480
increased cardiorespiratory 
fitness or increased 

531
00:27:47,480 --> 00:27:51,160
athleticism, you could say still
had decreased cardiovascular 

532
00:27:51,160 --> 00:27:53,080
risk. 
So there's definitely an 

533
00:27:53,080 --> 00:27:57,600
instance where having a higher 
calcium score on ACT scan. 

534
00:27:57,600 --> 00:27:59,960
That's probably the easiest way 
could contextualize. 

535
00:27:59,960 --> 00:28:03,440
It doesn't mean that your 
exercise is harming you, but 

536
00:28:03,440 --> 00:28:06,400
there's definitely a difference 
between a lower calcium score in

537
00:28:06,400 --> 00:28:09,640
the hundreds versus a calcium 
score in the thousands, with the

538
00:28:09,640 --> 00:28:11,720
latter definitely being 
something I would consider 

539
00:28:11,720 --> 00:28:14,080
pathology until proven 
otherwise. 

540
00:28:15,560 --> 00:28:19,440
The other things that we could 
see, so there's this question of

541
00:28:19,440 --> 00:28:24,560
is exercise pro arrhythmogenic, 
and the one arrhythmia I brought

542
00:28:24,560 --> 00:28:28,840
up was atrial fibrillation. 
A-fib is typically a situation 

543
00:28:28,840 --> 00:28:31,920
where you get these electrical 
currents coming from the top 

544
00:28:31,920 --> 00:28:35,920
left Chamber of the heart in an 
irregular dose and an irregular 

545
00:28:35,920 --> 00:28:38,480
smattering, and they tend to 
cause an irregular rhythm that 

546
00:28:38,480 --> 00:28:41,440
can be slow in its rate or very 
fast. 

547
00:28:41,640 --> 00:28:44,120
And sometimes people feel 
symptoms like difficulty 

548
00:28:44,120 --> 00:28:47,280
breathing, like they're pushing 
against a wall or lightheaded or

549
00:28:47,280 --> 00:28:49,360
dizzy. 
We typically see a fib in 

550
00:28:49,360 --> 00:28:52,280
individuals who are older. 
You know, old age is the number 

551
00:28:52,280 --> 00:28:56,200
one risk factor. 
But we are starting to see a fib

552
00:28:56,200 --> 00:28:59,520
in some of our athletes. 
And when I say we're starting to

553
00:28:59,520 --> 00:29:02,760
see, it's not a huge proportion 
of athletes, it's still few and 

554
00:29:02,760 --> 00:29:05,280
far between. 
But the thought process behind 

555
00:29:05,280 --> 00:29:08,640
this is that with exercise 
induced cardiac remodeling, 

556
00:29:08,640 --> 00:29:11,880
particularly endurance sport, if
we do see a little bit of 

557
00:29:11,880 --> 00:29:15,080
chamber enlargement in those 
areas of enlargement, 

558
00:29:15,080 --> 00:29:18,200
particularly in that left 
atrium, that top left chamber, 

559
00:29:18,360 --> 00:29:22,200
those areas become nitis for a 
little bit of scar and fibrosis 

560
00:29:22,200 --> 00:29:25,440
which become electrically active
and that can be the trigger for 

561
00:29:25,440 --> 00:29:28,320
atrial fibrillation. 
In athletes, we typically 

562
00:29:28,320 --> 00:29:32,760
describe this as lone Afib 
because athletes are most often 

563
00:29:32,760 --> 00:29:35,760
not everybody, but most often 
healthy with no other 

564
00:29:35,760 --> 00:29:39,520
cardiovascular issues. 
And we have studies that show 

565
00:29:39,520 --> 00:29:42,400
that exercise still helps to 
reduce the intensity and 

566
00:29:42,400 --> 00:29:45,560
frequency of a Fib. 
Big question for us becomes, is 

567
00:29:45,560 --> 00:29:48,920
there an exercise dose that is 
associated with increased risk 

568
00:29:48,920 --> 00:29:52,560
of a Fib versus not. 
And that exercise dose may be 

569
00:29:52,560 --> 00:29:57,040
around, at least based upon a 
couple of studies, 1500 to 2000,

570
00:29:57,040 --> 00:30:00,800
maybe more than 2000 lifetime 
hours of exercise, which if you 

571
00:30:00,800 --> 00:30:03,840
kind of try to do that 
mathematically, you know, that 

572
00:30:03,840 --> 00:30:07,160
could be even less than a decade
of, you know, 8 to 10 hours per 

573
00:30:07,160 --> 00:30:13,040
week of exercise consistently. 
But that's not enough data for 

574
00:30:13,040 --> 00:30:16,680
us to say, oh, you got to stop 
exercising now because we're 

575
00:30:16,680 --> 00:30:19,160
seeing atrial changes and you're
going to get a fib. 

576
00:30:19,640 --> 00:30:22,240
And my athletes who do have a 
FIB, and I've had people as 

577
00:30:22,240 --> 00:30:27,760
young as 17 year old competitive
rowers, to obviously my older 

578
00:30:27,760 --> 00:30:31,880
individuals, I still tell them 
exercise going to give you the 

579
00:30:31,880 --> 00:30:33,840
biggest cardiovascular bang for 
your buck. 

580
00:30:35,160 --> 00:30:38,000
And over time, it's going to 
keep you healthier and probably 

581
00:30:38,000 --> 00:30:41,080
keep you out of a fib longer 
than if you stopped exercising. 

582
00:30:41,320 --> 00:30:43,280
We know when you stopped 
exercising, the risk of 

583
00:30:43,280 --> 00:30:45,760
cardiovascular disease. 
And a lot of these 

584
00:30:45,760 --> 00:30:48,160
comorbidities, like a fib, just 
go drastically up. 

585
00:30:48,440 --> 00:30:52,120
So again, exercise is still 
good, but this is 1 particular 

586
00:30:52,120 --> 00:30:54,760
chronic cardiovascular change 
that you could see with it. 

587
00:30:56,920 --> 00:30:58,160
What are the other things? 
Fibrosis. 

588
00:30:58,160 --> 00:31:00,040
So that's like a very scary 
word. 

589
00:31:01,120 --> 00:31:04,480
When we break down the heart, we
think about the two sides, the 

590
00:31:04,480 --> 00:31:08,480
left side of the heart, which is
kind of the stronger pump part 

591
00:31:08,480 --> 00:31:11,880
of the heart, it pumps all the 
blood to your circulation, to 

592
00:31:12,120 --> 00:31:13,840
your fingers, your toes, your 
muscles. 

593
00:31:14,160 --> 00:31:16,360
And then we have also have the 
right side of the heart, which 

594
00:31:16,360 --> 00:31:19,000
is responsible for getting low 
pressure venous blood flow. 

595
00:31:19,440 --> 00:31:22,720
So if we look at the thickness 
of each of those chambers, the 

596
00:31:22,720 --> 00:31:27,280
left side is obviously thicker 
just to be able to provide that 

597
00:31:27,280 --> 00:31:31,200
increase contractility strength,
whereas the right side doesn't 

598
00:31:31,200 --> 00:31:33,520
have to be as thick, it's a 
thinner wall structure because 

599
00:31:33,600 --> 00:31:35,520
venous blood is a low pressure 
system. 

600
00:31:36,080 --> 00:31:39,080
Why is that important? 
So with exercise, even 

601
00:31:39,080 --> 00:31:42,400
transiently with endurance 
sport, we can see increase in 

602
00:31:42,400 --> 00:31:45,760
wall stress in the heart and 
those increases in wall stress 

603
00:31:45,760 --> 00:31:49,320
can lead to the release of this 
protein, this cardiac protein 

604
00:31:49,320 --> 00:31:53,160
called Troponin. 
Some listeners might be familiar

605
00:31:53,160 --> 00:31:55,000
with this. 
Now we hear about troponin 

606
00:31:55,000 --> 00:31:57,280
release, particularly in 
situations where people have 

607
00:31:57,280 --> 00:31:59,800
heart attacks. 
But it's not uncommon to have 

608
00:31:59,800 --> 00:32:03,880
this enzyme released with 
transient cardiac and I hate to 

609
00:32:03,880 --> 00:32:06,600
use this word but transient 
cardiac damage. 

610
00:32:07,200 --> 00:32:09,760
We've seen it in marathon 
runners, we've seen it in ultra 

611
00:32:09,760 --> 00:32:13,120
runners, it's transient. 
The troponin is released because

612
00:32:13,120 --> 00:32:15,320
the heart muscle is going 
through a little bit of micro 

613
00:32:15,320 --> 00:32:18,720
trauma, but that heart is still 
strong. 

614
00:32:18,760 --> 00:32:22,960
It does recover within a couple 
of hours to up to 72 hours 

615
00:32:22,960 --> 00:32:24,680
depending upon the duration of 
sport. 

616
00:32:25,520 --> 00:32:29,640
Over time, what we do see is 
that with endurance activity, 

617
00:32:29,760 --> 00:32:33,840
with the right side of the heart
being a little thinner, not 

618
00:32:34,000 --> 00:32:37,560
built for a high pressure system
like the left side, the right 

619
00:32:37,560 --> 00:32:40,440
ventricle can sometimes take a 
bigger hit than the left side 

620
00:32:40,720 --> 00:32:43,680
and sometimes we can see some 
chronic changes and fibrosis 

621
00:32:43,680 --> 00:32:46,280
there. 
But we don't have any evidence 

622
00:32:46,280 --> 00:32:50,080
to suggest that this increase in
fibrosis is related to an 

623
00:32:50,080 --> 00:32:53,520
increased risk of sudden death 
or increased risk of bad heart 

624
00:32:53,520 --> 00:32:56,640
rhythms that could kill you. 
So this seems to be some 

625
00:32:56,640 --> 00:33:02,240
exercise related change that may
be transient or maybe something 

626
00:33:02,240 --> 00:33:06,240
that is carried through, but 
there's just not enough evidence

627
00:33:06,240 --> 00:33:09,640
to date to say that this is 
going to be that harmful over 

628
00:33:09,640 --> 00:33:11,720
the long run. 
Thank you so much for all of 

629
00:33:11,720 --> 00:33:13,040
that. 
I think that will be really 

630
00:33:13,040 --> 00:33:16,080
helpful for our listeners who 
might be dealing with some of 

631
00:33:16,080 --> 00:33:18,840
these issues. 
And I'm glad you brought up the 

632
00:33:18,840 --> 00:33:22,680
fact that Troponin levels can be
temporarily elevated, for 

633
00:33:22,680 --> 00:33:26,200
example, after a marathon. 
Your blood work can be really 

634
00:33:26,200 --> 00:33:29,080
off after a marathon or an 
ultra, right? 

635
00:33:29,480 --> 00:33:34,120
So it's really actually a bad 
idea to get any blood work done 

636
00:33:34,120 --> 00:33:37,200
in like the week after a big 
race like that, because it's. 

637
00:33:37,760 --> 00:33:40,440
Potentially going to lead your 
doctors to conclude that 

638
00:33:40,440 --> 00:33:41,920
something is very wrong with 
you. 

639
00:33:42,200 --> 00:33:44,360
Yeah. 
And I even tell even when we do 

640
00:33:44,360 --> 00:33:47,920
testing in our athletes, if it's
going to be some form of cardiac

641
00:33:47,920 --> 00:33:51,120
testing, we typically say please
try not to exercise within 24 

642
00:33:51,120 --> 00:33:54,880
hours of of this test because it
can impact our results. 

643
00:33:55,200 --> 00:33:59,800
And you're exactly right. 
You know, we had just recently 

644
00:33:59,800 --> 00:34:02,560
there was a college athlete who 
got struck in the chest and they

645
00:34:02,560 --> 00:34:04,720
checked the troponin and it was 
a little elevated. 

646
00:34:04,720 --> 00:34:07,680
And the next question for me 
was, Oh my gosh, is this 

647
00:34:07,680 --> 00:34:10,400
cardiac? 
And I said, well, the kid just 

648
00:34:10,400 --> 00:34:12,840
came from a game. 
This is probably more game 

649
00:34:12,840 --> 00:34:16,199
related than impact related. 
So it's just again, kind of 

650
00:34:16,199 --> 00:34:18,199
taking all of these things into 
context. 

651
00:34:18,400 --> 00:34:20,760
And that also brings me, you 
know, to another point I wanted 

652
00:34:20,760 --> 00:34:23,120
to mention, you know, Troponin 
release heart attacks. 

653
00:34:23,120 --> 00:34:28,520
No, we hear more and more about 
individuals collapsing from 

654
00:34:28,520 --> 00:34:32,000
sudden cardiac arrest or sudden 
cardiac death at marathons, at 

655
00:34:32,000 --> 00:34:35,440
alter races, at cycling events. 
And you know, the question 

656
00:34:35,440 --> 00:34:39,120
always becomes, why did this 
person collapse? 

657
00:34:39,120 --> 00:34:40,880
Why did they have a heart 
attack? 

658
00:34:40,880 --> 00:34:43,000
Why did they die? 
And it could be someone as young

659
00:34:43,000 --> 00:34:47,239
as in their teens, or it could 
be someone as young as or 

660
00:34:47,239 --> 00:34:50,040
someone older kind of in the 
40s, fifties, masters athlete 

661
00:34:50,040 --> 00:34:53,679
range. 
And often times we don't 

662
00:34:53,679 --> 00:34:56,800
necessarily know what was the 
cause unless we have autopsy 

663
00:34:56,800 --> 00:34:58,800
data. 
But there was a wonderful study,

664
00:34:58,800 --> 00:35:02,720
the Racer study, that took a 
look at about, I want to say 10 

665
00:35:02,720 --> 00:35:05,120
million marathon and half 
marathon runners over about a 

666
00:35:05,120 --> 00:35:09,040
decade span of time. 
And out of all of those millions

667
00:35:09,040 --> 00:35:14,600
of runners, only 59 actually had
an event. 51 out of those 59 

668
00:35:14,600 --> 00:35:20,080
were males and the cause of 
cardiac arrest, so not death. 

669
00:35:20,120 --> 00:35:24,000
But the cause of cardiac arrest 
in the survivors was not what we

670
00:35:24,000 --> 00:35:29,040
think of like an acute heart 
attack where a little piece of 

671
00:35:29,040 --> 00:35:32,480
plaque breaks off, causes all 
these clotting factors to create

672
00:35:32,480 --> 00:35:36,400
a big clot or thrombus that then
prevents blood flow to a part of

673
00:35:36,400 --> 00:35:38,320
the heart muscle. 
So like when someone's clutching

674
00:35:38,320 --> 00:35:41,080
their chest and they're like, Oh
no, my heart hurts, my chest 

675
00:35:41,080 --> 00:35:43,280
hurts and they collapse. 
Those are kind of like those 

676
00:35:43,280 --> 00:35:46,160
catastrophic heart attacks I 
think of, but this was really 

677
00:35:46,160 --> 00:35:48,920
just people who actually had 
heart disease and had ischemic 

678
00:35:48,920 --> 00:35:52,760
heart disease meaning for the 
demand that they were requiring 

679
00:35:52,760 --> 00:35:55,680
on their body. 
They just couldn't meet the the 

680
00:35:55,680 --> 00:35:58,280
oxygen need. 
And so there was a bit of supply

681
00:35:58,280 --> 00:36:01,600
demand mismatch there and that's
why they had their arrest and 

682
00:36:01,600 --> 00:36:04,560
the people who actually died, 
that's where we saw actual what 

683
00:36:04,560 --> 00:36:07,040
we call cardiomyopathy. 
So disease of the heart muscle 

684
00:36:07,040 --> 00:36:11,080
itself, most commonly 
hypertrophic cardiomyopathy and 

685
00:36:11,080 --> 00:36:13,720
then some were actually related 
to low sodium levels for 

686
00:36:13,720 --> 00:36:16,280
hyperthermia. 
So there were other reasons for 

687
00:36:16,280 --> 00:36:19,360
cardiac arrest. 
And even looking at our colluded

688
00:36:19,360 --> 00:36:22,680
NCAA data, you know, I think a 
lot of us think that heart 

689
00:36:22,680 --> 00:36:24,880
muscle problems are the main 
cause of sudden death. 

690
00:36:24,880 --> 00:36:27,440
But you know, we're starting to 
see that it could be more 

691
00:36:27,440 --> 00:36:29,120
related to electrical 
disturbance. 

692
00:36:29,400 --> 00:36:32,200
And you can get that even within
a normal heart muscle from 

693
00:36:32,200 --> 00:36:35,200
situations where it's too hot. 
You get behind on hydration, you

694
00:36:35,200 --> 00:36:38,000
get behind on fueling, heat, 
stroke, heat, illness, those 

695
00:36:38,000 --> 00:36:40,840
things can take you down and you
know, having very markedly 

696
00:36:40,840 --> 00:36:43,520
abnormal sodium levels that can 
also lead to cardiac arrest. 

697
00:36:43,520 --> 00:36:48,560
So all those things again exist 
are very, very few and far 

698
00:36:48,560 --> 00:36:52,760
between. 
And we can really only do so 

699
00:36:52,760 --> 00:36:55,800
much in terms of protecting 
ourselves by 1 knowing our 

700
00:36:55,800 --> 00:36:59,560
family history, 2 knowing our 
personal history, 3 making sure 

701
00:36:59,560 --> 00:37:02,320
that we account for any 
cardiovascular issues we might 

702
00:37:02,320 --> 00:37:05,840
have because athletes are not 
immune to high blood pressure or

703
00:37:05,840 --> 00:37:08,920
high cholesterol or common 
things like that or even 

704
00:37:08,920 --> 00:37:12,600
diabetes. 
And then for being aware. 

705
00:37:12,600 --> 00:37:16,400
So be aware of your hydration, 
your fueling, your body's 

706
00:37:16,400 --> 00:37:19,920
capabilities, understand you 
know if there's true 

707
00:37:19,920 --> 00:37:23,560
physiological limits that you 
just need to pay heed to. 

708
00:37:23,640 --> 00:37:25,640
And then I always say, learn how
to do CPR. 

709
00:37:26,360 --> 00:37:29,280
That's probably the the biggest 
skill that you could have. 

710
00:37:29,280 --> 00:37:34,040
But again, these arrests and 
deaths that we see in the media 

711
00:37:34,040 --> 00:37:36,640
or sometimes live are not 
reasoning enough for you to stop

712
00:37:36,640 --> 00:37:38,920
doing what you enjoy doing. 
Just be smart about. 

713
00:37:38,920 --> 00:37:40,800
It definitely, yeah. 
Thank you. 

714
00:37:40,800 --> 00:37:43,440
That's a really important point 
to make I think, because the 

715
00:37:43,520 --> 00:37:48,120
anytime, you know, sadly 
somebody dies at an event, it's 

716
00:37:48,120 --> 00:37:51,240
covered extensively in the 
media, but you know the other 

717
00:37:51,240 --> 00:37:55,840
49,900 people. 
That did not happen to. 

718
00:37:55,840 --> 00:37:59,760
So it's easy to make these 
events seem more common than 

719
00:37:59,760 --> 00:38:02,720
they are, but the reality is 
they are not common. 

720
00:38:04,040 --> 00:38:08,440
So what you're all what you just
mentioned leads into my next 

721
00:38:08,440 --> 00:38:11,160
question, which is about pre 
participation screening. 

722
00:38:11,400 --> 00:38:15,400
So pre participation screening 
is required for collegiate 

723
00:38:15,400 --> 00:38:19,880
athletes and most professional 
athletes, which is essential for

724
00:38:19,880 --> 00:38:23,000
detecting potential problems 
before they become serious or 

725
00:38:23,000 --> 00:38:25,440
fatal. 
Is there a role for pre 

726
00:38:25,440 --> 00:38:28,960
participation screening for 
recreational endurance athletes?

727
00:38:29,280 --> 00:38:34,480
So if somebody you know like you
took up running in grad school 

728
00:38:34,800 --> 00:38:38,520
started doing longer and longer 
races, they were never in a 

729
00:38:38,520 --> 00:38:43,080
formal system where they were 
required to have cardiac 

730
00:38:43,080 --> 00:38:47,600
screening. 
Should people who are increasing

731
00:38:47,600 --> 00:38:50,760
their training or running 
marathons or getting to some 

732
00:38:51,080 --> 00:38:54,880
level of activity? 
Have a pre participation 

733
00:38:54,880 --> 00:38:57,600
screening and if so, how should 
they go about getting that? 

734
00:38:58,160 --> 00:39:00,720
Yes, you know screening or 
cardiac risk assessment is very 

735
00:39:00,720 --> 00:39:02,960
interesting because it's not 
even mandated in the United 

736
00:39:02,960 --> 00:39:05,920
States. 
It's not mandated mandated by 

737
00:39:05,920 --> 00:39:07,960
the NCAA. 
And we typically have that 

738
00:39:07,960 --> 00:39:12,040
program here that we piloted 
several years ago just to help 

739
00:39:12,040 --> 00:39:14,400
streamline a lot of 
symptomatology that we were 

740
00:39:14,400 --> 00:39:17,600
seeing, quite common among 
athletes being heart racing 

741
00:39:17,600 --> 00:39:20,480
sensations or palpitations, 
People feel like they were going

742
00:39:20,480 --> 00:39:22,920
to pass out or passing out or 
chest discomfort. 

743
00:39:23,360 --> 00:39:26,600
And cardiac risk assessment has 
its pros and its cons. 

744
00:39:26,760 --> 00:39:29,720
The pros are, yes, you could 
catch some things that could be 

745
00:39:30,000 --> 00:39:32,240
associated with increased 
cardiovascular risk. 

746
00:39:32,480 --> 00:39:34,760
But the cons are, if you don't 
have the people who know what 

747
00:39:34,760 --> 00:39:38,240
they're reading meaning, don't 
know how to read as athlete EKG,

748
00:39:38,520 --> 00:39:41,480
don't know how to interpret 
symptoms, cardiac testing, don't

749
00:39:41,480 --> 00:39:44,360
know what to do with family 
history information, then you're

750
00:39:44,360 --> 00:39:47,640
going to be leading a lot of 
athletes down this road of doing

751
00:39:47,640 --> 00:39:50,440
a lot of downstream testing that
is expensive and likely 

752
00:39:50,440 --> 00:39:52,960
unnecessary. 
And then you might even find 

753
00:39:52,960 --> 00:39:56,880
some incidental stuff that has 
nothing to do with why they 

754
00:39:56,880 --> 00:39:59,560
initially were getting 
evaluated, but now you got to 

755
00:39:59,560 --> 00:40:03,320
deal with and we forget, you 
know, it's it's easy I think for

756
00:40:03,320 --> 00:40:08,160
providers to get kind of 
streamlined or tunnel vision 

757
00:40:08,160 --> 00:40:10,600
into. 
What's I need to do this, this, 

758
00:40:10,600 --> 00:40:13,600
this, this, this. 
Next you can easily forget about

759
00:40:13,600 --> 00:40:17,280
the psyche of the athlete. 
You know, oftentimes these 

760
00:40:17,280 --> 00:40:19,440
individuals, specifically 
college athletes, are really 

761
00:40:19,440 --> 00:40:20,760
young. 
You know, the last thing they 

762
00:40:20,760 --> 00:40:22,440
want to do is see a 
cardiologist. 

763
00:40:22,720 --> 00:40:25,800
And now you're telling them that
they can't play because of this 

764
00:40:25,800 --> 00:40:28,640
finding on a sheet of paper and 
now this other study and this 

765
00:40:28,640 --> 00:40:30,680
other study. 
So those are reasons why there 

766
00:40:30,680 --> 00:40:33,280
could be and there is 
controversy about whether or not

767
00:40:33,280 --> 00:40:36,960
we should actually mandate 
cardiovascular evaluations for 

768
00:40:36,960 --> 00:40:39,320
our older athletes. 
So, you know, people who, like 

769
00:40:39,320 --> 00:40:42,280
you were mentioning out of grad 
school or masters athletes, if 

770
00:40:42,280 --> 00:40:45,080
you're looking into getting a 
little more intense or 

771
00:40:45,080 --> 00:40:48,400
incorporating greater exercise 
dose for a particular sport, 

772
00:40:49,560 --> 00:40:51,800
then you know, there's certain 
checks that we should do. 

773
00:40:51,800 --> 00:40:54,840
I mean, one is often times we're
really good about, you know, 

774
00:40:54,840 --> 00:40:58,560
doing things like our prehab and
our warmups and our dynamic 

775
00:40:58,560 --> 00:41:01,400
stretches. 
Why don't we shift that over 

776
00:41:01,400 --> 00:41:05,560
into looking at our own physical
health and our personal medical 

777
00:41:05,560 --> 00:41:08,680
history and our family history? 
So if you're someone who knows 

778
00:41:08,680 --> 00:41:11,720
that you've had many, many 
family members who've died in 

779
00:41:11,720 --> 00:41:15,120
their thirties, 40s or 50s from 
heart disease, that's abnormal. 

780
00:41:15,120 --> 00:41:17,880
You know, that is a big red flag
for someone like me. 

781
00:41:18,200 --> 00:41:21,200
And if you're thinking now about
doing high intensity sport, I 

782
00:41:21,200 --> 00:41:23,560
would definitely go to a 
provider and say, look, I have a

783
00:41:23,560 --> 00:41:26,400
considerable family history for 
heart problems. 

784
00:41:26,400 --> 00:41:30,520
This is what I know of and can 
we look into my own risk and see

785
00:41:31,160 --> 00:41:33,640
is there something that I should
modify with respect to my 

786
00:41:33,640 --> 00:41:36,360
activity? 
And oftentimes, you know a lot 

787
00:41:36,360 --> 00:41:40,040
of people are healthy, but it 
gets you into a consistent 

788
00:41:40,040 --> 00:41:43,600
practice where you're not only 
taking care of the checks you 

789
00:41:43,600 --> 00:41:46,520
need for running or endurance 
sport, but you're also taking 

790
00:41:46,520 --> 00:41:49,400
care of the checks you need for 
your physical well-being to be 

791
00:41:49,400 --> 00:41:53,040
able to do what you want to do. 
You know, it's wonderful to take

792
00:41:53,040 --> 00:41:56,560
care of your muscles and your 
tendons and your bones, but at 

793
00:41:56,560 --> 00:41:59,440
the end of the day, we still 
need our organs and our heart to

794
00:41:59,440 --> 00:42:02,720
keep functioning. 
So I don't necessarily know if 

795
00:42:03,160 --> 00:42:05,840
something like that would be 
ever mandated for, you know, 

796
00:42:05,840 --> 00:42:10,160
people out of school. 
But I do encourage individuals. 

797
00:42:10,160 --> 00:42:12,480
If you have something in your 
medical history where you're 

798
00:42:12,480 --> 00:42:16,880
like, I know I've got really 
high cholesterol or my blood 

799
00:42:16,880 --> 00:42:19,200
pressure has been really high 
and I haven't seen a doctor 

800
00:42:19,200 --> 00:42:22,600
recently, those are issues where
you should go and see someone, 

801
00:42:23,200 --> 00:42:25,960
someone like me, where we can 
say, you know, isn't EKG the 

802
00:42:25,960 --> 00:42:28,480
next appropriate step. 
Again, it's not the best 

803
00:42:28,480 --> 00:42:31,920
screening tool, it's very cheap,
cost effective tool. 

804
00:42:32,960 --> 00:42:35,760
But we can at least then be a 
little more specific about what 

805
00:42:35,760 --> 00:42:39,440
you as an individual may need 
for us to assess what your risk 

806
00:42:39,440 --> 00:42:43,160
is moving forward to do the 
level of activity you want to do

807
00:42:43,160 --> 00:42:44,640
at the intensity you want to do 
it at. 

808
00:42:44,960 --> 00:42:48,280
Yeah, I think that's great. 
And emphasizing, if you have a 

809
00:42:48,280 --> 00:42:51,840
significant family history for 
cardiac disease, then that makes

810
00:42:51,840 --> 00:42:55,760
a better case for an 
asymptomatic individual to go 

811
00:42:55,760 --> 00:42:56,680
get checked out. 
Yeah. 

812
00:42:56,680 --> 00:42:58,720
And it's not even just heart 
disease, like I said. 

813
00:42:58,720 --> 00:43:02,840
So the big things for me are, 
has anyone in your family died 

814
00:43:02,840 --> 00:43:05,200
at a really young age, just 
suddenly out of the blue? 

815
00:43:05,520 --> 00:43:07,880
So what I'm getting at is, was 
there any family history of 

816
00:43:07,880 --> 00:43:11,000
sudden cardiac death? 
That's a huge red flag. 

817
00:43:11,640 --> 00:43:14,160
Did anybody die in their teens 
or in their 20s? 

818
00:43:14,160 --> 00:43:16,760
Huge red flag. 
Anybody who's living with a 

819
00:43:16,760 --> 00:43:19,800
known heart problem. 
What is that heart problem? 

820
00:43:20,120 --> 00:43:22,920
Does anybody have a 
defibrillator in their chest? 

821
00:43:22,920 --> 00:43:25,080
At what age was it implanted and
why? 

822
00:43:25,120 --> 00:43:28,040
Or a pacemaker? 
So those types of things. 

823
00:43:28,320 --> 00:43:31,120
And then, you know, outside of 
that family history, it's really

824
00:43:31,120 --> 00:43:33,040
asking about your own personal 
symptoms. 

825
00:43:33,280 --> 00:43:35,400
What happens when you run? 
What do you feel? 

826
00:43:35,400 --> 00:43:38,880
Do you ever get chest discomfort
or difficulty breathing that 

827
00:43:38,880 --> 00:43:41,280
seems disproportionate to the 
amount of effort you're putting 

828
00:43:41,280 --> 00:43:44,320
in and then we can parcel out? 
Is this overtraining? 

829
00:43:44,320 --> 00:43:47,680
Is this iron deficiency? 
Is this thyroid abnormality or 

830
00:43:47,680 --> 00:43:49,960
is this cardiac? 
And does this warrant additional

831
00:43:49,960 --> 00:43:51,880
testing? 
You're essentially doing your 

832
00:43:51,880 --> 00:43:55,480
own stress test every day, like 
going out there and running. 

833
00:43:55,880 --> 00:43:59,560
But that gives people like me so
much information because there 

834
00:43:59,560 --> 00:44:02,680
could be a huge difference if 
you're telling me, you know 

835
00:44:02,680 --> 00:44:06,600
what, I usually run my marathon 
pace at six minutes per mile, 

836
00:44:06,600 --> 00:44:09,160
but I'm noticing but sleep not 
changed. 

837
00:44:09,160 --> 00:44:12,280
My hydration and my fueling is 
all where it's been. 

838
00:44:12,280 --> 00:44:16,640
My nutrition is great, but my 
marathon pace is really hard at 

839
00:44:16,640 --> 00:44:19,520
610. 
Like now I'm at six, 10615. 

840
00:44:19,520 --> 00:44:22,760
I can't explain it and that's a 
big red flag for me. 

841
00:44:22,760 --> 00:44:25,560
Whereas for someone else, they 
might just say, oh, that's 

842
00:44:25,560 --> 00:44:27,960
really fast anyway, like it's 
just 10 seconds. 

843
00:44:28,280 --> 00:44:31,840
But that has allowed for us to 
identify people who have very 

844
00:44:31,840 --> 00:44:35,520
severe heart disease. 
And that was the big clue. 

845
00:44:36,000 --> 00:44:41,520
So you know your body so well, 
share that information with us. 

846
00:44:41,520 --> 00:44:45,800
You know we do look at you know,
smart watch data and stuff like 

847
00:44:45,800 --> 00:44:47,480
that. 
You know, obviously with a grain

848
00:44:47,480 --> 00:44:50,640
of salt, but pattern recognition
is what we're looking for, 

849
00:44:50,640 --> 00:44:54,080
whether it comes to our own 
cardiac testing or your own 

850
00:44:54,080 --> 00:44:56,800
personal data. 
So those are kind of a lot of 

851
00:44:56,800 --> 00:45:00,080
ways that we can hopefully get 
ahead of something if something 

852
00:45:00,080 --> 00:45:03,040
were to happen versus kind of 
having that fear in the back of 

853
00:45:03,040 --> 00:45:05,960
our mind of am I going to be 
that person who, you know 

854
00:45:06,000 --> 00:45:07,680
doesn't make it through this 
marathon? 

855
00:45:07,840 --> 00:45:09,600
You know, we never want to have 
that mindset. 

856
00:45:09,880 --> 00:45:10,560
Right. 
Yeah. 

857
00:45:10,840 --> 00:45:13,640
Act on facts, not on fear. 
Right. 

858
00:45:14,320 --> 00:45:17,320
Yeah. 
So let's move on to endurance 

859
00:45:17,320 --> 00:45:20,480
athletes who are experiencing 
cardiac symptoms. 

860
00:45:20,840 --> 00:45:23,120
And this is a really personal 
topic for me. 

861
00:45:23,480 --> 00:45:26,600
A few years ago, one of my 
friends died as a result of an 

862
00:45:26,760 --> 00:45:29,640
undiagnosed cardiac issue. 
He died on his bike. 

863
00:45:31,000 --> 00:45:34,480
And several others have had 
heart attacks, have been 

864
00:45:34,480 --> 00:45:37,920
diagnosed with a fib with 
ventricular tachycardia. 

865
00:45:38,400 --> 00:45:41,720
One of my friends survived in 
the aortic dissect dissection 

866
00:45:42,120 --> 00:45:48,640
and several of them feel like 
even now they do not have good 

867
00:45:48,640 --> 00:45:52,400
guidance about what the 
appropriate level of physical 

868
00:45:52,400 --> 00:45:56,320
activity is and the main reason 
is they feel like. 

869
00:45:56,680 --> 00:45:59,240
There just aren't any 
cardiologists around here who 

870
00:45:59,240 --> 00:46:03,200
understand the type of training 
that they used to do and 

871
00:46:03,200 --> 00:46:05,680
understand what they would like 
to get back to doing. 

872
00:46:06,160 --> 00:46:09,680
So I just wanted to provide an 
episode for our listeners 

873
00:46:09,680 --> 00:46:12,760
because I'm sure that there are 
so many people out there who 

874
00:46:12,760 --> 00:46:17,120
either know somebody who have 
experienced A cardiac issue or 

875
00:46:17,120 --> 00:46:20,600
they're experiencing symptoms 
themselves and they just don't 

876
00:46:20,600 --> 00:46:22,840
know what the right path is to 
proceed. 

877
00:46:23,640 --> 00:46:27,400
So what would you tell an 
athlete who is experiencing new 

878
00:46:27,400 --> 00:46:31,320
symptoms, such as their heart 
rate spiking really high, that 

879
00:46:31,320 --> 00:46:35,440
doesn't correspond with their 
level of effort, Palpitations, 

880
00:46:35,440 --> 00:46:37,200
chest pain? 
Shortness of breath? 

881
00:46:37,640 --> 00:46:40,120
What should they do? 
Go and see someone. 

882
00:46:40,280 --> 00:46:43,800
And if you do have access to a 
sports cardiologist in your area

883
00:46:43,800 --> 00:46:48,640
or are aware of someone who may 
be in a place that you're able 

884
00:46:48,640 --> 00:46:52,200
to travel to, definitely seek 
someone else who understands the

885
00:46:52,200 --> 00:46:58,040
physical capacities, kind of the
physical nature of sports, what 

886
00:46:58,040 --> 00:47:01,760
each sport type can do from a 
physiologic perspective, so they

887
00:47:01,760 --> 00:47:04,000
can understand the context that 
you're providing. 

888
00:47:04,400 --> 00:47:05,680
Right. 
So if you're going to someone 

889
00:47:05,680 --> 00:47:08,840
who doesn't exercise, doesn't 
know much about running, and 

890
00:47:08,840 --> 00:47:11,880
you're saying, hey, you know, I 
run like 30 miles a week, 

891
00:47:11,880 --> 00:47:15,000
they're going to say holy moly, 
30 miles a week. 

892
00:47:15,040 --> 00:47:17,520
That's a lot. 
And then you follow that up by 

893
00:47:17,520 --> 00:47:20,160
saying I used to run 100 miles 
per week and now I can only run 

894
00:47:20,160 --> 00:47:22,840
30. 
You know, that's very different.

895
00:47:23,200 --> 00:47:25,880
So the first thing I would do is
don't sweep these types of 

896
00:47:25,880 --> 00:47:29,160
symptoms under the rugs because 
there's the two things I always 

897
00:47:29,160 --> 00:47:32,720
say are, one, most likely it's 
nothing. 

898
00:47:33,520 --> 00:47:36,120
But two, it could be something 
and we catch it now before it 

899
00:47:36,120 --> 00:47:38,760
catches you. 
And then the other thing to 

900
00:47:38,760 --> 00:47:44,160
remember is the psychological 
kind of effects of holding on to

901
00:47:44,160 --> 00:47:47,120
symptoms that are concerning 
you, that you're just a little 

902
00:47:47,120 --> 00:47:50,760
too nervous to get checked out. 
And sometimes I see that people 

903
00:47:50,760 --> 00:47:52,920
are nervous because they don't 
want their training cycle to be 

904
00:47:52,920 --> 00:47:55,240
interrupted, They don't want to 
lose fitness. 

905
00:47:55,240 --> 00:47:57,160
They're scared someone's going 
to tell them they can't do what 

906
00:47:57,160 --> 00:47:59,960
they want to do, They don't want
to mix the next thing. 

907
00:48:00,160 --> 00:48:04,720
But I always try to say, look, 
if we nip something in the bud 

908
00:48:04,720 --> 00:48:09,160
now, you will have years and 
years and years of participation

909
00:48:09,160 --> 00:48:13,200
and doing what you want to do. 
If we identify something now and

910
00:48:13,200 --> 00:48:16,560
it's harmful, maybe we've 
identified it early enough where

911
00:48:16,560 --> 00:48:21,400
we can modify and still have you
do certain movements or certain 

912
00:48:21,400 --> 00:48:24,360
sports that still bring you joy,
but they just look a little 

913
00:48:24,360 --> 00:48:26,440
different. 
So definitely see someone who 

914
00:48:26,440 --> 00:48:29,560
could help you parcel out what 
things are worrisome and what 

915
00:48:29,560 --> 00:48:31,600
are not. 
And then, you know, see someone 

916
00:48:31,600 --> 00:48:35,120
who's specific to your 
symptomatology to help regulate 

917
00:48:35,120 --> 00:48:36,800
the type of testing that you 
would need. 

918
00:48:37,440 --> 00:48:39,960
Usually for my athletes, you 
know I love cardio pulmonary 

919
00:48:39,960 --> 00:48:44,120
exercise testing or VO2 Max 
testing for several different 

920
00:48:44,160 --> 00:48:46,120
reasons. 
One, you know, it gives me an 

921
00:48:46,240 --> 00:48:49,440
understanding of someone's 
fitness capacity and it also 

922
00:48:49,440 --> 00:48:52,360
allows for me to get someone to 
do the type of exercise that's 

923
00:48:52,520 --> 00:48:55,960
not foreign to them. 
So this is not a typical, quote 

924
00:48:55,960 --> 00:48:57,920
UN quote stress test where 
you're just walking up an 

925
00:48:57,920 --> 00:49:00,800
incline every 3 minutes and it 
changes an incline of speed. 

926
00:49:01,000 --> 00:49:03,200
I'm having you run. 
I'm trying to simulate the thing

927
00:49:03,200 --> 00:49:06,160
that brings about your symptoms 
or I can have you bike to try to

928
00:49:06,160 --> 00:49:09,280
simulate your symptoms. 
So there's different things that

929
00:49:09,280 --> 00:49:14,160
we can do on our lab to recreate
the situation that makes you 

930
00:49:14,280 --> 00:49:17,760
feel like something is hurting 
or makes you feel like there's 

931
00:49:17,760 --> 00:49:19,760
something that's that's holding 
you back. 

932
00:49:20,080 --> 00:49:24,320
So let's say somebody for the 
PAT for a week, they go on their

933
00:49:24,320 --> 00:49:28,520
runs and their heart rate just 
spikes, you know, to 2:30 and 

934
00:49:28,520 --> 00:49:30,760
their Max heart rate is normally
170. 

935
00:49:32,280 --> 00:49:35,960
Unless they go to the ER, 
they're probably not going to 

936
00:49:35,960 --> 00:49:39,720
get seen right away. 
So what should that person do 

937
00:49:39,720 --> 00:49:43,000
between the time that they 
notice this pattern of symptoms 

938
00:49:43,440 --> 00:49:45,480
and actually getting in to be 
evaluated? 

939
00:49:45,480 --> 00:49:49,080
Because I think that could 
potentially be a dangerous point

940
00:49:49,080 --> 00:49:52,200
where they're experiencing 
symptoms but their primary care 

941
00:49:52,200 --> 00:49:55,800
can't see them for a month, a 
cardiologist can't see them for 

942
00:49:55,800 --> 00:49:58,640
six months. 
Should they go to urgent care? 

943
00:49:59,040 --> 00:50:03,000
I mean, the ER, unless they're 
having an acute event, the ER 

944
00:50:03,000 --> 00:50:04,920
probably isn't the appropriate 
place for them. 

945
00:50:04,920 --> 00:50:07,080
So what would you recommend in 
terms of? 

946
00:50:07,440 --> 00:50:10,200
Being seen in a timely manner, 
Yeah. 

947
00:50:10,320 --> 00:50:13,360
I mean, unfortunately I can't 
control what people are seeing 

948
00:50:13,360 --> 00:50:16,080
outside of my own clinic. 
And these are situations where, 

949
00:50:16,520 --> 00:50:19,760
you know, we in our Sports 
Credology center understand kind

950
00:50:19,760 --> 00:50:24,240
of the timeliness of of what a 
sport requires, You know, 

951
00:50:24,240 --> 00:50:26,800
whether it be a team sport. 
And knowing that keeping someone

952
00:50:26,800 --> 00:50:29,880
out for three weeks just to wait
to get to be seen is like half 

953
00:50:29,880 --> 00:50:32,400
of the season. 
So we really try to get people 

954
00:50:32,400 --> 00:50:34,960
in within 24 to 48 hours of 
symptomatology. 

955
00:50:35,360 --> 00:50:38,440
But if you're not able to or you
don't have access to that, not 

956
00:50:38,440 --> 00:50:40,760
able to do that, I think the 
first couple of questions you 

957
00:50:40,760 --> 00:50:42,120
could probably answer on your 
own. 

958
00:50:42,120 --> 00:50:46,560
So over that course of week, you
know, ask yourself, did anything

959
00:50:46,560 --> 00:50:49,800
else change from a stress 
perspective, Stress being things

960
00:50:49,800 --> 00:50:53,920
like sleep again, hydration, 
your nutrition, If you've had 

961
00:50:53,920 --> 00:50:56,640
access to recent labs, what are 
your iron levels looking like? 

962
00:50:58,160 --> 00:51:01,360
Stress and anxiety, you know, or
did something change in your 

963
00:51:01,360 --> 00:51:04,560
fitness and maybe are you 
overtraining now and then look 

964
00:51:04,560 --> 00:51:07,160
at how your data was acquired. 
So if you're seeing these heart 

965
00:51:07,160 --> 00:51:10,240
rate sparks spikes because 
you're using a smart watch, are 

966
00:51:10,240 --> 00:51:13,040
you someone who just uses a 
watch alone or do you use a 

967
00:51:13,040 --> 00:51:14,560
chest strap? 
Because the chest strap is going

968
00:51:14,560 --> 00:51:16,840
to be inherently a little more 
accurate than the than the 

969
00:51:16,840 --> 00:51:20,160
watch. 
Then you can kind of go back and

970
00:51:20,160 --> 00:51:23,640
trace over your trends and see, 
OK, it looks, I have, it looks 

971
00:51:23,640 --> 00:51:26,560
like I have a spike here. 
How did I feel during that 

972
00:51:26,560 --> 00:51:28,720
spike? 
Did I just look down on my watch

973
00:51:28,720 --> 00:51:32,880
and say, oh, it says 230, but I 
feel great and it's probably not

974
00:51:32,880 --> 00:51:35,280
an abnormality, it's probably an
inaccuracy. 

975
00:51:35,600 --> 00:51:39,400
But if you at 2:30 were like, Oh
my God, I can't breathe, I'm 

976
00:51:39,400 --> 00:51:42,680
going to pass out or my heart's 
just being out of my chest. 

977
00:51:43,400 --> 00:51:46,120
Trust your gut, you know, it's 
in my mind. 

978
00:51:46,120 --> 00:51:49,160
It's probably something that 
requires further evaluation 

979
00:51:49,160 --> 00:51:52,480
until proven otherwise. 
But those are at least some kind

980
00:51:52,480 --> 00:51:54,560
of easy checks that you can do 
on your own. 

981
00:51:54,840 --> 00:51:57,880
But if you truly, if let's say 
you have those spikes over the 

982
00:51:57,880 --> 00:52:01,000
week and then all of a sudden 
you're stuck in a spike and the 

983
00:52:01,000 --> 00:52:04,320
two hundreds should definitely 
go to urgent care or emergent 

984
00:52:04,320 --> 00:52:06,560
care. 
And then even on the market now 

985
00:52:06,560 --> 00:52:08,800
you know there's a number of 
devices out there. 

986
00:52:09,440 --> 00:52:12,720
And I I say this with the caveat
of if you're someone who's more 

987
00:52:12,720 --> 00:52:17,400
on the anxious level or having 
access to more things makes you 

988
00:52:17,400 --> 00:52:19,960
more anxious and more stressed, 
then don't do this. 

989
00:52:20,760 --> 00:52:23,160
But if you're 7, you can have a 
little bit more control about 

990
00:52:23,160 --> 00:52:24,720
that. 
There are devices out there 

991
00:52:24,720 --> 00:52:28,200
where you can actually record 
your heart rhythm outside of, 

992
00:52:28,280 --> 00:52:30,600
you know, I know even now Garmin
has EKG features. 

993
00:52:30,600 --> 00:52:33,600
But outside of things like that,
like the cardio mobile device, 

994
00:52:33,600 --> 00:52:35,880
you put your fingers on this 
kind of metal strip and it can 

995
00:52:35,880 --> 00:52:39,640
record your EKG or even the 4th 
frontier chest strap which can 

996
00:52:39,640 --> 00:52:43,600
actually show you your rhythm 
with pretty good accuracy. 

997
00:52:43,840 --> 00:52:46,840
These are some ways to at least 
get things recorded, get them on

998
00:52:46,840 --> 00:52:48,880
APDF. 
So you could say, hey doc, I 

999
00:52:48,880 --> 00:52:51,760
know you can't see me, but I do 
have some data. 

1000
00:52:52,120 --> 00:52:54,320
And you know, here within our 
electronic medical record 

1001
00:52:54,320 --> 00:52:58,280
system, we've got really easy 
communication among patients and

1002
00:52:58,280 --> 00:53:01,080
providers. 
And you know, usually we're, I'm

1003
00:53:01,080 --> 00:53:03,920
responding within 24 hours. 
Most people are responding 

1004
00:53:03,920 --> 00:53:07,800
within 24 to 72, but that might 
be an easy way to say, I've got 

1005
00:53:07,800 --> 00:53:09,600
some data, This is how I'm 
feeling. 

1006
00:53:09,880 --> 00:53:13,760
I know I have yet to see you, 
but these things are concerning 

1007
00:53:13,760 --> 00:53:15,360
me. 
Is there anything that you could

1008
00:53:15,360 --> 00:53:18,920
offer just based upon some of 
the pronouns that I'm providing 

1009
00:53:18,920 --> 00:53:21,920
or sending your way. 
So those are I think some ways 

1010
00:53:21,920 --> 00:53:28,080
to kind of try to try to feel 
the unfortunate issues with our 

1011
00:53:28,080 --> 00:53:30,480
healthcare system of trying to 
see someone when you need to be 

1012
00:53:30,480 --> 00:53:31,480
seen. 
Yes. 

1013
00:53:31,560 --> 00:53:36,000
And I think the point of like, 
how did you feel when your watch

1014
00:53:36,000 --> 00:53:37,840
said it was 220? 
Because, yeah, we've all 

1015
00:53:37,840 --> 00:53:41,680
experienced, you know, you start
out your easy run and it says 

1016
00:53:41,680 --> 00:53:43,000
your heart rate's through the 
roof. 

1017
00:53:43,000 --> 00:53:46,640
And you know, it's not, it's 
just dry air or whatever. 

1018
00:53:46,640 --> 00:53:49,640
It's an anomaly. 
But if your heart rate feels 

1019
00:53:49,640 --> 00:53:52,840
like it's 2:20, then that's a 
more serious issue for sure. 

1020
00:53:53,840 --> 00:53:57,160
So. 
As we've discussed a little bit 

1021
00:53:57,160 --> 00:53:59,440
already, there aren't a lot of 
people like you out there. 

1022
00:53:59,800 --> 00:54:02,920
But do you do telehealth 
consults? 

1023
00:54:02,920 --> 00:54:05,440
Like, how could a person who 
doesn't have a sports 

1024
00:54:05,440 --> 00:54:09,800
cardiologist in their area 
connect with an expert like you 

1025
00:54:09,800 --> 00:54:14,520
to get the best opinion for what
they should do regarding both 

1026
00:54:14,520 --> 00:54:18,000
their health and their training?
Yeah, so at least within our 

1027
00:54:18,000 --> 00:54:20,280
sports cardiology center here at
the Cleveland Clinic, I mean, we

1028
00:54:20,280 --> 00:54:24,120
do telehealth visits. 
We do second opinions and some 

1029
00:54:24,120 --> 00:54:26,520
of these things are a little bit
restricted by the states that we

1030
00:54:26,520 --> 00:54:29,200
are licensed in, my Co director 
and myself. 

1031
00:54:29,920 --> 00:54:33,040
But we're more than happy to to 
help anyone that we can. 

1032
00:54:33,040 --> 00:54:35,480
And we have our own kind of 
e-mail system too. 

1033
00:54:35,480 --> 00:54:38,160
And if someone sends an e-mail 
and says hey, I'm in this 

1034
00:54:38,160 --> 00:54:40,480
location but I just don't know 
who to get in touch with. 

1035
00:54:40,840 --> 00:54:44,920
And we're more than happy to 
help you kind of by looking at 

1036
00:54:44,920 --> 00:54:47,560
our own community and finding 
providers who might be of easy 

1037
00:54:47,560 --> 00:54:49,840
access to you. 
And we're happy to answer 

1038
00:54:49,840 --> 00:54:51,800
questions. 
Obviously, you know, clinical 

1039
00:54:51,800 --> 00:54:54,840
questions are challenging to 
answer outside of an office 

1040
00:54:54,840 --> 00:54:58,040
visit, you know, from kind of a 
legality perspective. 

1041
00:54:58,040 --> 00:55:01,160
But I think most of us really 
just want to be as helpful as 

1042
00:55:01,160 --> 00:55:04,240
possible and can at least answer
some things in a more 

1043
00:55:04,360 --> 00:55:07,880
generalizable fashion. 
Sports cardiology centers are 

1044
00:55:07,880 --> 00:55:10,600
popping up kind of everywhere. 
I feel like it's suddenly 

1045
00:55:10,600 --> 00:55:13,880
becoming a bit trendy. 
But I do, you know, counsel you 

1046
00:55:13,880 --> 00:55:16,360
to make sure that whoever you 
see has been doing this or has 

1047
00:55:16,360 --> 00:55:20,000
been trained to do this so that 
you're not seeing kind of 

1048
00:55:20,040 --> 00:55:22,720
anybody who just says, hey, I 
like athletes or I'm an athlete 

1049
00:55:22,720 --> 00:55:25,120
myself, and so I'm doing sports 
cardiology. 

1050
00:55:25,840 --> 00:55:29,080
But you know, my partner here 
and I have been doing this for 

1051
00:55:29,080 --> 00:55:32,480
years and we can vouch for other
people within our community who 

1052
00:55:32,480 --> 00:55:35,920
are excellent at what they do in
the East Coast, on the West 

1053
00:55:35,920 --> 00:55:40,320
Coast, here in the Midwest and 
even in the Southeast as well. 

1054
00:55:40,320 --> 00:55:44,400
So we're more than happy to try 
to connect you to whoever might 

1055
00:55:44,400 --> 00:55:46,560
be closest to you. 
That's great and thank you so 

1056
00:55:46,560 --> 00:55:48,640
much for that. 
Is there a professional 

1057
00:55:48,640 --> 00:55:52,720
organization for sports 
cardiologists that maybe has a 

1058
00:55:52,720 --> 00:55:57,520
website with a registry of who? 
Actually has the knowledge not 

1059
00:55:57,520 --> 00:55:59,840
just calls themselves a sports 
cardiologist. 

1060
00:55:59,960 --> 00:56:02,240
I would say the best place to go
to is the American College of 

1061
00:56:02,240 --> 00:56:05,240
Cardiology website. 
We have our own an exercise in 

1062
00:56:05,240 --> 00:56:08,040
sports Cardiology council and 
there is typically a list of 

1063
00:56:08,040 --> 00:56:10,640
different sports cardiology 
centers or sports cardiologists 

1064
00:56:10,640 --> 00:56:15,160
who are involved with the ACC. 
Most of us who are with involved

1065
00:56:15,160 --> 00:56:18,080
within the ACC or have been 
doing this for several years or 

1066
00:56:18,080 --> 00:56:21,400
have been trained or at least 
have gone through, you know, a 

1067
00:56:21,400 --> 00:56:25,520
number of the educational 
curriculum that that I think you

1068
00:56:25,520 --> 00:56:28,400
need to go through in order to 
understand how to take care of 

1069
00:56:28,400 --> 00:56:30,840
an athlete. 
That would be the best starting 

1070
00:56:30,840 --> 00:56:31,920
point. 
OK, great. 

1071
00:56:32,200 --> 00:56:35,040
And we'll throw those links in 
the show notes so that our 

1072
00:56:35,040 --> 00:56:39,120
listeners can check those out. 
So once, let's say an athlete 

1073
00:56:39,120 --> 00:56:41,440
has been diagnosed with an 
issue, let's say they've been 

1074
00:56:41,440 --> 00:56:45,560
diagnosed with a Fib. 
How does a sports cardiologist 

1075
00:56:45,560 --> 00:56:49,040
determine what dosage and 
intensity of training is safe? 

1076
00:56:49,400 --> 00:56:52,680
And I know that it's specific to
an individual, but like, what 

1077
00:56:52,680 --> 00:56:55,200
process would you use to help 
figure that out? 

1078
00:56:55,760 --> 00:56:58,800
So often times it's a lot of the
data that the athlete patient 

1079
00:56:58,800 --> 00:57:00,960
has themselves. 
So sometimes they'll say, you 

1080
00:57:00,960 --> 00:57:04,920
know, I'm these types of rides 
or these types of runs. 

1081
00:57:04,920 --> 00:57:07,720
When I do this particular 
intensity, that's when I notice 

1082
00:57:07,720 --> 00:57:10,480
I go into a fib. 
But if I pull back, I go out of 

1083
00:57:10,480 --> 00:57:13,360
it and we then kind of get a 
general sense of the intensity, 

1084
00:57:13,760 --> 00:57:16,120
how long it lasts. 
And most importantly, does it 

1085
00:57:16,120 --> 00:57:18,720
evoke symptoms? 
Does it evoke symptoms that make

1086
00:57:18,720 --> 00:57:22,080
you want to stop, make you feel,
you know, just not good? 

1087
00:57:22,080 --> 00:57:24,440
Or is it something where you're 
like, I don't even notice that 

1088
00:57:24,440 --> 00:57:28,160
I'm in a fib, for instance? 
Those things are typically what 

1089
00:57:28,160 --> 00:57:31,880
helped me determine the exercise
load or the exercise 

1090
00:57:31,880 --> 00:57:34,240
prescription. 
But it's a shared decision. 

1091
00:57:34,360 --> 00:57:36,960
You know, it ends up being, you 
know, what does my athlete feel 

1092
00:57:36,960 --> 00:57:40,000
comfortable doing? 
We can use testing, like stress 

1093
00:57:40,000 --> 00:57:43,480
testing to define perhaps 
specific intensities if we 

1094
00:57:43,480 --> 00:57:45,880
notice. 
Or if the athlete patient says 

1095
00:57:45,880 --> 00:57:51,440
to me, you know, when I'm going 
at like a 5 1/2 minute clip, 

1096
00:57:51,440 --> 00:57:53,960
that's when I go into my A-fib. 
You know, we can try to 

1097
00:57:53,960 --> 00:57:56,800
reproduce that and see, is this 
truly A-fib or is this maybe 

1098
00:57:56,800 --> 00:57:59,680
just a really rapid heart rate 
that he can't distinguish from a

1099
00:57:59,720 --> 00:58:01,600
fib? 
And that might be enough to 

1100
00:58:01,600 --> 00:58:04,160
provide some reassurance, saying
actually you're not even an 

1101
00:58:04,160 --> 00:58:06,440
A-fib in that situation. 
You're in a normal rhythm. 

1102
00:58:06,960 --> 00:58:09,080
And that might help reassure 
them that they're doing okay and

1103
00:58:09,080 --> 00:58:10,320
they can continue what they're 
doing. 

1104
00:58:10,880 --> 00:58:13,280
If it comes to something more 
along the flavors of a 

1105
00:58:13,280 --> 00:58:16,000
cardiomyopathy, so an actual 
abnormality within the heart 

1106
00:58:16,000 --> 00:58:18,520
muscle that could be related to 
an increased risk of sudden 

1107
00:58:18,520 --> 00:58:21,280
cardiac arrest or death, then 
things kind of change. 

1108
00:58:21,360 --> 00:58:23,960
There are certain flavors of 
cardiomyopathy where we're 

1109
00:58:23,960 --> 00:58:27,880
becoming a little more liberal 
with respect to exercise 

1110
00:58:27,880 --> 00:58:32,280
capacity and that includes 
hypertrophic cardiomyopathy and 

1111
00:58:32,480 --> 00:58:35,040
that's where cardio pulmonary 
exercise testing or stress 

1112
00:58:35,040 --> 00:58:38,000
testing can be helpful because 
there might be a certain 

1113
00:58:38,000 --> 00:58:41,080
threshold particularly defined 
by heart rate where we're 

1114
00:58:41,080 --> 00:58:43,840
noticing increased abnormal 
heart rhythm versus not. 

1115
00:58:44,160 --> 00:58:46,480
And that might be the threshold 
where I say, hey, let's try to 

1116
00:58:46,480 --> 00:58:51,480
keep exercise below this heart 
rate, understanding that if that

1117
00:58:51,480 --> 00:58:55,720
heart rates in their kind of 
zone to work area, they're 

1118
00:58:55,720 --> 00:58:57,920
probably going to continue to 
get fitter, right? 

1119
00:58:57,920 --> 00:59:00,680
And as they get fitter, that 
exercise intensity is going to 

1120
00:59:00,680 --> 00:59:03,840
be done at a lower heart rate. 
And so that heart rate might 

1121
00:59:03,840 --> 00:59:06,280
change. 
So kind of doing surveillance 

1122
00:59:06,280 --> 00:59:09,400
testing and that way will help 
us kind of keep tabs on what is 

1123
00:59:09,400 --> 00:59:11,400
proarrhythmogenic versus what is
not. 

1124
00:59:11,680 --> 00:59:15,920
Things may change over the years
if the expression of the disease

1125
00:59:15,920 --> 00:59:17,840
also changes. 
Thank you. 

1126
00:59:18,000 --> 00:59:21,120
That's a great explanation. 
That's very helpful to hear. 

1127
00:59:21,120 --> 00:59:24,160
Just your thought process for 
different types of cardiac 

1128
00:59:24,160 --> 00:59:27,000
issues. 
So we got a bunch of listener 

1129
00:59:27,000 --> 00:59:30,040
questions for this episode and 
in the interest of time, I just 

1130
00:59:30,040 --> 00:59:36,560
want to ask you one of them from
Karen K just she said she or he 

1131
00:59:36,560 --> 00:59:40,600
said we would love to hear about
any connections between COVID 

1132
00:59:40,600 --> 00:59:44,400
and cardiac changes in runners. 
So we know that there are some 

1133
00:59:44,400 --> 00:59:47,600
associations, but could you tell
us what they are? 

1134
00:59:47,600 --> 00:59:50,960
What people should be on the 
lookout for, if they have COVID 

1135
00:59:50,960 --> 00:59:54,520
or recently had it, Yeah. 
So I think when COVID first came

1136
00:59:54,520 --> 00:59:58,440
out, you know, the big word that
was out in media was 

1137
00:59:58,440 --> 01:00:01,440
myocarditis, which is basically 
inflammation of a heart muscle 

1138
01:00:02,160 --> 01:00:04,840
that can be associated with 
increased risk of cardiac arrest

1139
01:00:04,840 --> 01:00:07,880
or death, which is why it's kind
of like a, quote, UN quote, big 

1140
01:00:07,880 --> 01:00:10,600
name in the viral world from a 
cardiac perspective. 

1141
01:00:10,960 --> 01:00:13,800
You can get myocarditis from 
anything from the flu, from 

1142
01:00:13,800 --> 01:00:17,160
COVID, from any viral entity or 
from really anything that can 

1143
01:00:17,160 --> 01:00:20,240
trigger heart inflammation. 
So that caused kind of the 

1144
01:00:20,240 --> 01:00:22,760
biggest area of concern, at 
least when we started to look. 

1145
01:00:22,840 --> 01:00:28,920
At our own athletes and post 
COVID cardiac evaluations being 

1146
01:00:28,920 --> 01:00:32,480
a bit more aggressive to start 
what I mean by that doing an EKG

1147
01:00:32,480 --> 01:00:35,520
or heart ultrasound and maybe 
even a heart MRI to now 

1148
01:00:35,520 --> 01:00:37,960
realizing that the actual 
incidence of myocarditis is 

1149
01:00:37,960 --> 01:00:42,800
extremely, extremely low, less 
than 1% based upon the 

1150
01:00:42,800 --> 01:00:45,760
collegiate data that we have. 
So very few and far between 

1151
01:00:46,320 --> 01:00:50,400
acutely with COVID infection. 
From a cardiac perspective, when

1152
01:00:50,400 --> 01:00:53,880
we think about our athletes, 
it's like any other viral 

1153
01:00:53,880 --> 01:00:55,320
illness. 
You know, if you're feeling 

1154
01:00:55,320 --> 01:00:59,200
crummy, if you're not, well, 
understand that your body is 

1155
01:00:59,200 --> 01:01:01,840
dealing with additional stress, 
The last thing you want to do is

1156
01:01:01,840 --> 01:01:04,160
compound it with the stress of 
exercise. 

1157
01:01:04,440 --> 01:01:07,640
As much as we think it might 
make us feel better, stress upon

1158
01:01:07,640 --> 01:01:09,560
stress is probably going to make
you feel worse. 

1159
01:01:09,920 --> 01:01:12,560
So I say respect the viral 
illness, respect the illness and

1160
01:01:12,560 --> 01:01:14,520
get that rest and recovery you 
need. 

1161
01:01:14,800 --> 01:01:20,120
It's like inflammation in your 
ankle or tendonitis or something

1162
01:01:20,120 --> 01:01:21,760
mild. 
If you've got that little 

1163
01:01:21,760 --> 01:01:25,360
niggle, take care of it in those
first couple of days versus 

1164
01:01:25,560 --> 01:01:28,080
waiting for it to turn into a 
full blown injury that takes you

1165
01:01:28,080 --> 01:01:31,480
out six or seven weeks. 
And then based upon your 

1166
01:01:31,480 --> 01:01:34,120
symptomatology and how you're 
feeling, you can then start to 

1167
01:01:34,240 --> 01:01:36,360
amplify. 
You know, I usually say start 

1168
01:01:36,360 --> 01:01:40,160
with a lower intensity amount of
exercise and if you're feeling 

1169
01:01:40,160 --> 01:01:42,920
good, slowly ramp it up. 
So kind of like a return to play

1170
01:01:42,920 --> 01:01:45,480
protocol that you could easily 
do with a musculoskeletal 

1171
01:01:45,480 --> 01:01:48,280
injury. 
A lot of the things that I'm 

1172
01:01:48,280 --> 01:01:53,200
seeing with COVID or acute COVID
or maybe even subacute COVID is 

1173
01:01:53,480 --> 01:01:55,560
fluctuations in heart rate. 
That's probably one of the 

1174
01:01:55,560 --> 01:01:59,200
biggest things people will say. 
My heart rate goes sky high when

1175
01:01:59,200 --> 01:02:01,360
I'm just walking from 1:00 room 
to the other. 

1176
01:02:01,640 --> 01:02:04,560
Usually my resting heart rate's 
in the 40s, now it's in the 70s,

1177
01:02:04,560 --> 01:02:06,800
eighties. 
That's abnormal for me. 

1178
01:02:06,920 --> 01:02:10,320
That again is probably a marker 
of stress versus a marker of a 

1179
01:02:10,320 --> 01:02:13,520
cardiac abnormality. 
We have to understand that, you 

1180
01:02:13,520 --> 01:02:16,600
know, our heart rate is also 
regulated by our nervous system,

1181
01:02:16,640 --> 01:02:19,360
by our sympathetic, our fight 
and flight system and our 

1182
01:02:19,360 --> 01:02:21,680
parasympathetic, our rest and 
digest system. 

1183
01:02:22,040 --> 01:02:24,520
And that autonomic nervous 
system regulates everything from

1184
01:02:24,520 --> 01:02:26,000
our head to our toes and our 
body. 

1185
01:02:26,320 --> 01:02:28,920
So if we've got a stress, it's 
kind of like fight or flight, 

1186
01:02:28,920 --> 01:02:30,920
our heart rates probably going 
to go up, our blood pressure may

1187
01:02:30,920 --> 01:02:33,880
also be up. 
And then the other things too is

1188
01:02:33,880 --> 01:02:36,920
when we're, you know not 
necessarily bed rest, but we're 

1189
01:02:36,920 --> 01:02:39,200
not as active as we typically 
want to be. 

1190
01:02:39,640 --> 01:02:41,320
Our plasma volume adjusts for 
that. 

1191
01:02:41,320 --> 01:02:43,400
It goes a little lower. 
Our heart rate goes up a little 

1192
01:02:43,400 --> 01:02:46,320
bit, we're a little more 
dehydrated, people can get a 

1193
01:02:46,320 --> 01:02:49,280
little light headed. 
So a lot of that stuff is what I

1194
01:02:49,280 --> 01:02:53,840
hear about the majority of the 
time outside of acute COVID, we 

1195
01:02:53,840 --> 01:02:59,080
have post COVID syndrome so that
it is now really seen as a 

1196
01:02:59,120 --> 01:03:00,960
disability at least here in 
America. 

1197
01:03:01,280 --> 01:03:04,480
Because I would say probably 30 
to 40% of individuals at least 

1198
01:03:04,480 --> 01:03:08,800
with the initial virus strains 
developed post COVID syndrome 

1199
01:03:08,800 --> 01:03:13,760
and I've seen it less and less 
with the change in in the virus 

1200
01:03:13,760 --> 01:03:16,040
strains over the last year or 
two. 

1201
01:03:16,600 --> 01:03:19,680
Post COVID syndrome is really 
challenging to manage especially

1202
01:03:19,680 --> 01:03:22,800
for athletes. 
That was and still remains, 

1203
01:03:22,800 --> 01:03:26,680
probably a decent amount of my 
patient panel people who used to

1204
01:03:26,680 --> 01:03:31,320
run or do endurance sport and 
never had any, never had any 

1205
01:03:31,320 --> 01:03:33,640
issues with exercise, never had 
health problems. 

1206
01:03:33,640 --> 01:03:38,880
And suddenly, again like those 
smallest intensity of movement, 

1207
01:03:38,880 --> 01:03:43,200
the lightest of the lightest jog
makes them feel awful, causes 

1208
01:03:43,200 --> 01:03:47,000
chest pain, difficulty 
breathing, heart, heart rate, 

1209
01:03:47,000 --> 01:03:49,680
escalations, sometimes passing 
out. 

1210
01:03:49,800 --> 01:03:52,640
And all of this, you know, is 
just mentally exhausting, 

1211
01:03:52,640 --> 01:03:55,960
Physically exhausting can lead 
to post traumatic stress, can 

1212
01:03:55,960 --> 01:04:00,120
lead to depression. 
And so I found that particularly

1213
01:04:00,120 --> 01:04:03,960
challenging to manage because 
there's oftentimes nothing wrong

1214
01:04:03,960 --> 01:04:05,600
from a cardiovascular 
perspective. 

1215
01:04:06,440 --> 01:04:09,680
And what we're finding at least 
from a hypothesis perspective is

1216
01:04:09,680 --> 01:04:12,920
it could be related to you know 
their autonomic nervous system. 

1217
01:04:12,920 --> 01:04:16,760
It could be related to vascular 
health, so vessel health or 

1218
01:04:16,760 --> 01:04:20,760
endothelial health. 
It could be related to retain 

1219
01:04:20,760 --> 01:04:22,720
viral particles in the gut. 
There's so many different 

1220
01:04:22,720 --> 01:04:25,720
hypothesis for why post COVID 
syndrome has has come about. 

1221
01:04:25,720 --> 01:04:28,720
But you know if we think about 
it, we've had post viral 

1222
01:04:28,720 --> 01:04:31,880
syndromes for decades and 
decades, right? 

1223
01:04:31,880 --> 01:04:34,720
You know, we have EVV and 
lymphoma, we have hepatitis and 

1224
01:04:34,720 --> 01:04:38,680
cirrhosis. 
So this is I think new for all 

1225
01:04:38,680 --> 01:04:41,800
of us because for reasons so 
used to having something come 

1226
01:04:42,000 --> 01:04:47,400
and then leave quickly and never
stay and continue to harm us. 

1227
01:04:48,160 --> 01:04:50,680
But those are probably a lot of 
the things that I hear that 

1228
01:04:50,680 --> 01:04:52,760
sound like cardiovascular 
symptoms. 

1229
01:04:52,760 --> 01:04:56,040
It could be cardiovascular and 
origin, but nearly always are 

1230
01:04:56,040 --> 01:04:57,720
not. 
Yeah, so of course getting 

1231
01:04:57,720 --> 01:05:01,040
checked out, making sure that 
they are not, and then getting 

1232
01:05:01,040 --> 01:05:05,320
to the appropriate person to 
help with the root cause if the 

1233
01:05:05,320 --> 01:05:08,120
root cause can be determined 
exactly. 

1234
01:05:08,720 --> 01:05:13,080
Again, well, Doctor Singh, this 
has been just such an amazing 

1235
01:05:13,080 --> 01:05:15,000
episode. 
Thank you so much for joining 

1236
01:05:15,000 --> 01:05:17,120
me. 
Do you have any closing thoughts

1237
01:05:17,120 --> 01:05:21,440
for our listeners regarding just
anything we've talked about? 

1238
01:05:21,760 --> 01:05:25,760
If you're experiencing symptoms,
what you would recommend, how to

1239
01:05:25,760 --> 01:05:29,240
keep your heart healthy? 
Just any last words for our 

1240
01:05:29,240 --> 01:05:32,320
listeners here. 
Yeah, I think, you know, when 

1241
01:05:32,560 --> 01:05:37,320
you finish up listening to this 
wonderful podcast episode, I 

1242
01:05:37,320 --> 01:05:40,440
don't want listeners to leave 
thinking something's wrong with 

1243
01:05:40,440 --> 01:05:43,400
me. 
I want listeners to leave 

1244
01:05:43,400 --> 01:05:46,760
feeling empowered. 
Like you have a new skill set to

1245
01:05:46,760 --> 01:05:48,800
evaluate yourself in a different
way. 

1246
01:05:49,120 --> 01:05:51,240
And that evaluation is not 
always negative. 

1247
01:05:51,240 --> 01:05:53,440
It could be positive. 
It could be a way to learn about

1248
01:05:53,440 --> 01:05:56,040
yourself, learn about things 
that maybe you didn't think 

1249
01:05:56,040 --> 01:05:59,200
about, or maybe pay attention to
symptomatology that you thought 

1250
01:05:59,200 --> 01:06:01,760
you could just kind of push 
under the rug. 

1251
01:06:02,240 --> 01:06:05,160
Now, our bodies, and I think as 
athletes, we become really in 

1252
01:06:05,160 --> 01:06:09,080
tune to our bodies, and we focus
a lot on our muscles and our 

1253
01:06:09,600 --> 01:06:12,840
musculoskeletal system. 
But if you're feeling something 

1254
01:06:12,840 --> 01:06:15,680
centrally, if you're feeling 
like there's some effort that 

1255
01:06:15,680 --> 01:06:19,120
you didn't anticipate in the 
work that you're doing, or if 

1256
01:06:19,120 --> 01:06:21,880
your guts just telling you 
something's weird, something is 

1257
01:06:21,880 --> 01:06:26,040
off, get it checked out, you 
know, rip off that Band-Aid face

1258
01:06:26,040 --> 01:06:29,240
that face, that fear. 
Because often times you know 

1259
01:06:29,240 --> 01:06:32,720
that fear is going to turn into 
reassurance and you'll go into 

1260
01:06:32,720 --> 01:06:36,640
your next race or into your next
endurance effort just feeling 

1261
01:06:36,640 --> 01:06:40,640
psychologically relieved and 
confident in what you're doing. 

1262
01:06:41,160 --> 01:06:45,080
So I think it just bear in mind 
that a lot of things we talked 

1263
01:06:45,080 --> 01:06:48,240
about happen in a very small 
cohort of individuals. 

1264
01:06:48,680 --> 01:06:51,840
We are not immune to 
cardiovascular problems, but we 

1265
01:06:51,840 --> 01:06:57,000
are in control of how we choose 
to live our lives as individuals

1266
01:06:57,000 --> 01:07:00,240
and as a community. 
So utilize the resources and the

1267
01:07:00,240 --> 01:07:05,080
network that we have, the powers
of the socials and the powers of

1268
01:07:05,080 --> 01:07:09,080
good evidence based medicine and
we're here to to help you stay 

1269
01:07:09,080 --> 01:07:11,360
as healthy as possible. 
Absolutely love it. 

1270
01:07:11,600 --> 01:07:15,600
Thank you so much, Doctor Singh 
and Willie and the show notes 

1271
01:07:15,600 --> 01:07:18,160
leave where to find Doctor 
Singh's practice. 

1272
01:07:19,120 --> 01:07:21,960
As always, we appreciate your 
questions. 

1273
01:07:22,440 --> 01:07:26,440
Please leave us a review either 
on YouTube or on your podcast 

1274
01:07:26,440 --> 01:07:29,160
platform and we'll see you next 
time. 

1275
01:07:29,600 --> 01:07:30,520
Thanks everybody.