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Posted by Dr. Sushrut Jangi April 8, 2013 03:13 PM
Most of us have heard of Jim Fixx - the celebrity author of The Complete Guide to Running who got America hooked onto jogging. Ironically, he died of a sudden heart attack at a young age of 52 after one of his daily runs and was found to have extensive blockages in the coronaries supplying his heart.
Every so often, we hear of athletic tragedies - last fall an 18 year old lineman fatally collapsed after a tackle at his team's homecoming game from a heart arrhythmia. And just this weekend, a 24 year old died during a half-marathon in Berlin, according to preliminary reports.
But such dramatic stories - however haunting and unfortunate - don't stop Americans from making vigorous exercise a part of their lives. A decade ago, about 1 million people participated in long-distance races each year. As of 2010, that number has climbed to 2 million. Here in Boston, about 10,000 people registered for the Boston Marathon in 1992; last year that number more than doubled to nearly 22,000 participants. That the popularity of marathons continues to increase is no surprise. Even though Jim Fixx is long gone, the legacy of his lifestyle is apparent in the average Bostonian. On many of the city's street corners we find evidence of this perpetual health renaissance: yoga centers are as common-place as coffeehouses, organic fruits are sold at Downtown Crossing even in the dark of December, and thousands of joggers brave the ice along the Charles River in mid-winter. Recently, Forbes Magazine rated Boston the third-healthiest city in the country. We've begun to believe that attaining good health requires constant, even aggressive attention to the condition of the body. The lifestyle of the marathoner - the long, dutied morning runs, the loyalty to a good diet, and participating in the annual day of reckoning, is a homage to challenging the self and bringing us closer to our ideal health. But is running a marathon - in actuality - good for us? Or are the apparent dangers the media intermittently reports a kind of warning?
To find out, I went to see Dr. Baggish, a young and bright cardiologist at MGH who is also the associate director of the Cardiovascular Performance Program. His clinic is anything but ordinary. The seats in his waiting room, for the most part, are occupied by athletes young and old. Among his patients are marathoners, mountain-climbers, and competitive bicyclists. Many come into his clinic armed with reams of data from their Garmin and Polar Heart Rate Monitors, a collection of physiologic parameters and race performance times exhaustively organized into spreadsheets. "Most of the patients I see are highly motivated," he laughs. But although Dr. Baggish is no stranger to the language of athletics (he has run 30 marathons himself), he is not seeing his patients to compare long-distance times. Instead, he is systematically searching his patients for red flags, early signs that suggest an athlete may be at high risk for heart disease. "Being athletic," he warns, "in no way grants you any kind of immunity."
When the Boston Marathon first began more than a century ago, the doctors of yesteryear were actually really worried. They considered marathoners akin to astronauts or pioneers, crazy people full of bravado who were testing the limits of the human physique. Consider the medical paranoia in this 1903 report from The New England Journal of Medicine documenting the race that year:
The course covers a rolling country, one or two hills, notably in Newton, being extremely long and trying. Each contestant is accompanied by an official guard on bicycle, usually a volunteer from the Ambulance Service of the State Militia. At the end of the race, they were taken in the elevator to the dressing rooms of the clubhouse and immediately examined.
Although we no longer have personal escorts for every marathoner in 2013, the Boston Marathon is still taken seriously by the medical community. A station is set up every mile along the route with supplies for first aid along with cardiac defibrillators. Some of the stations have bags of intravenous saline, EKG machines, and computers that can analyze blood chemistries in seconds. "We have the ability to track every runner, medically," says Chris Troyanos, the medical coordinator for the event. "There are barcodes built into bibs and wristbands. We know when runners check into emergency rooms at any of the Boston hospitals. We know when they check out." The ten hospitals along the route are on high-alert; their emergency rooms declare the Boston Marathon a "mass casualty event," the same category reserved for bioterrorism or natural disasters. Clearly, more than a hundred years later, it appears the medical community is still worried. Why are we so cautious?
Dr. Baggish ran his first marathon in 1997 when he was twenty-one years old, years before he became a doctor. He had no concerns - he says he was blind to the concept of risk. Nowadays, he has changed his perspective a bit. Of all the athletes he sees in his clinic, many - like him - will go on to run dozens of marathons without a problem. But among those athletes, there are a select few who are high risk for experiencing an event. "I've seen many of these people who have gotten into trouble with real heart disease," Dr. Baggish says. He refers to the exercise paradox: that exercise is the best way to reduce cardiac disease, but a cardiac event is most likely to occur during exercise. "A marathon is not inherently dangerous," he says. "But if you are already at risk for a heart attack, the marathon might bring it out."
Okay - then how to figure out who is at risk before such an event occurs? Dr. Baggish shrugs, implying that it's not easy to figure that out. The common symptoms of heart disease - chest pressure, shortness of breath, nausea - are often absent in devoted athletes. Instead, he says, the signs are more subtle. For instance, when Dr. Baggish reviews the performance times and heart rate spreadsheets his athletes so dutifully document, he looks for sudden changes in exercise habits: a sudden drop-off in performance or a new heart-rate trend. Most at-risk athletes do have traditional risk factors, like high cholesterol or high blood pressure. But many will forego getting treated, expecting their vigorous exercise regimens will afford them protection. In other words, athletes often wear a veil of immunity that does not really exist. "These people end up getting missed," Dr. Baggish says.
Now, with the upcoming Boston Marathon next week, Dr. Baggish's vigilance has been kicked into high gear. He offers a set up of tips for every runner. He urges respecting periodicity, or ensuring that runners build up towards the marathon, with equal periods of exercise and recovery. Similarly, he directs attention to warming up and cooling down. "The body hates abrupt starts and stops," he says. On marathon day, he asks runners to adjust their expectations according to what the day brings to them. For example, during last year's marathon, the temperature rose to nearly ninety degrees Farenheit, a situation that prompted organizers to offer participants an automatic requalification for 2013 if they opted not to run in the scorching heat. Most runners ran anyway. "You should be willing to change your routine on marathon day if necessary," Dr. Baggish reminds everyone. Finally, if you're sick with a virus, even something as slight as a cold, he suggests staying at seventy percent of the maximal heart rate.
Despite his suggestions, some will go to emergency rooms or will have trouble during the race. The chances of something extreme happening - like a heart attack - are exceedingly low. According to his group's study, the chances of a runner experiencing a cardiac event during a long distance race is 1 in 184,000. "You're more likely to die in a car crash going to and from the event," Dr. Baggish says. Still - the best thing runners can do to minimize such an event is to avoid a surge of activity during the last few miles of the race. When heart attacks do occur, its often in the last quarter, when participants decide to push themselves harder, a practice that can lead to undue strain on the heart muscle.
The Boston Athletic Association, which hosts the annual race, is obviously aware of the potential dangers of long-distance running. The BAA sends out emails to all participants on how to avoid heat stroke or overhydration. "We even teach the runners to pay attention to each other, so that if someone goes down, they can help start CPR," Troyanos says. "We're the first marathon in the country to do that." This year, in 2013, they have more medical cots than ever before, in part to reduce the strain on the local hospitals. Dr. Baggish will be at the front-lines to help provide medical assistance to anyone in need. But despite his calls for caution, he does not want to discourage the practice of running marathons. "Yes, every so often, there is a tragedy." But such events are still rare. "There is so much good that comes from this lifestyle," he says, his face brightening.
I won't be running the marathon this year - I get shin splits (whatever those are). But I'll be watching. I remember when I was a kid, it was part of my family's tradition to gather at the sidelines of Route 135 every spring with cut slices of oranges in our hands, until a sweaty marathoner swiped the fruit from our palms. When the runners finally arrived around the bend, their inhalations, the drumming of their feet against the asphalt, and their steady exhalations were the sounds of otherwordly machines. I never considered them flesh-and blood human; to me, they were composed of elbows, pivots, tendons and pistons. Now that I've grown up a bit, I've found that the truth is even more surprising: those who run the Boston Marathon each year (some of whom are my colleagues) are regular, disciplined people who often complete the marathon without any serious problems and go on to run several more. Dr Baggish's enthusiasm is encouraging. "I fully believe," he says, "that routine, consistent exercise and training, including training for a marathon or two each year, is the key to long-term health." Maybe one day, I'll try it myself. For now, I think, opening my notepad, I'm okay writing about it.
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About the authorSushrut Jangi is an internist at Beth Israel Deaconess Medical Center and an editorial fellow at The New England Journal of Medicine. More »
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