Post 38 - Cardiology

The past few weeks have been a difficult time with all the problems and issues I’ve had. I’ve been monitoring myself and my body very closely, looking for signs of recovery, signs that I can up the training again, or signs telling me to ease off and give myself more time to recover. The trouble is, if I am to compete at Ironman Wales on 14^th September, I don’t really have a lot of time. Further trouble is that I am due to spend ten days in the French Alps from next week, avec mon vélo/with my bike. I’ll be staying at a campsite by a lake, with loads of high Tour de France mountains nearby. It will be great training for Wales, because not a single part of the Wales course is flat.

However, health is the number one priority. If I’m not happy that I’m healthy enough and recovered enough then I can’t push myself in training, I can’t ride up 7000-foot mountains in France, and there will be a question mark over Wales.

I’ve recently noticed a few odd heartbeats. Nothing prolonged, or nothing that makes me feel like I’m about to collapse, but just the very odd soft/hard beat, along with a strange feeling. Everything is normal, then boom, the funny flutter and funny feeling comes, and then a second or two later, it’s gone. These feelings have perhaps been compounded by being fairly stressed over the past weeks, and perhaps because I am very lean at the minute, and had a high level of fitness, and a low but strong resting heartbeat, I’m more inclined to notice my heartbeats.

I was wondering what on earth was going on. Was it something benign and not to be worried about, or was it something that the infection had brought on? Was it something serious? Was it risky to train hard? Should I be training at all? I realised that thinking about doing another high level Ironman so soon, or even going out to the Alps to train at altitude, was something that could only be done after an investigation and an all-clear.

I’d already been checked over a million times in hospital, I’d had a medical check-up just before Ironman UK, and I had a more thorough medical check-up immediately after Ironman UK , which included an electrocardiogram heart analysis. All of these checks were absolutely fine, but I felt I needed something a bit more in-depth. An electrocardiogram only monitors the heart’s activity for a very short period of time. I knew that an ultrasonic echocardiogram, which takes longer to carry out, looks in detail at the heart’s structure. I also knew that 24 or 48 hour electrocardiograms were possible, and if I had one of these, hopefully it would pick up one or two of these irregular heartbeats to allow it to be analysed in detail.

I also know that doing Ironman triathlons and the associated training, elevating the heart rate for prolonged periods of time, does put a lot of stress on the body. Many other athletes at a similar level would be getting regular detailed heath and heart check-ups. I’ve never had a detailed heart examination and felt it was something worth doing, for peace of mind and to get the confidence back that I can push myself hard in training and racing.

I knew the whole process would be a nightmare. Arranging appointments. Travelling around London in its maddening crowds and maddening public transport (I really, really hate doing this). Spending ages in waiting rooms. Possibly having to take time off work, or leaving work early, or coming in late. Compromising my training. Possibly compromising my sleep. A nightmare. But it had to be done. So I phoned the NHS (National Health Service) non-emergency number to ask for advice. They said the first thing to do was to see a doctor. I know that it can take weeks to get an appointment, so I phoned the surgery at exactly 9am the next morning, right at opening time. I got through straight away and asked for an emergency appointment. Later that day, I saw a doctor.

I explained the situation and he did some initial checks, and said everything seemed fine, but that a 24-hour electrocardiogram would be a good idea. He said that on the NHS, it would take a few weeks for the appointment to come through. This was no good to me. I had 2 weeks before going to the Alps. I wanted an all-clear before the trip. Fortunately, I have private medical insurance with my work, so I was able to go to a private hospital after a lengthy phone call with my insurers to discuss the problem and cross my fingers that they would cover everything. They said they would, so very soon I found myself talking to a cardiologist at a private hospital in east London.

He did his initial checks and said everything seemed fine. He wanted to do another short electrocardiogram, then an echocardiogram, and a 48-hour electrocardiogram monitor. This needed another phone call to the insurers to see if these would all be covered, which they agreed to. The initial electrocardiogram only took a few minutes and involved him attaching about ten electrodes to my chest, shoulders and ankles. These then fed into a computer that produced a print-out of what my heart was doing.

I could see him looking at the print-out of the electrical activity of my heartbeat. I could see he wasn’t completely happy, and he said, “Now, I’m going to have to tell you this…” For a split second I was worried. He explained that the results showed that I had slightly thickened heart muscle.

I already knew this was common in endurance athletes, and I also knew that very thick muscle was a bad thing. He said an echocardiogram would determine just how thick, but that his initial impressions were that it didn’t seem abnormally thick. He then explained his diagnosis: Ectopic heartbeats. During our discussions, I really grilled him on everything I could possibly think of.

Ectopic heartbeats are actually really common in most people, but they are generally not noticed. There are a huge number of cells in the heart that must all fire electrically at precisely the same time to make the heart beat. There are four chambers in the heart, each of which will expand and contract. Sometimes, a very small number of these cells can fire prematurely, which causes the ectopic heartbeat. It is essentially a weaker beat, followed by a corrective stronger beat. It causes a strange sensation, but only lasts for a couple of beats. I was only experiencing them fairly infrequently, and so I was reassured by the cardiologist that there was nothing to worry about.

When you are more in tune with your body, and when you have a really low body fat and a strong, low heart beat, these ectopic beats can become much more noticeable. Also with a low heart rate associated with a high level of fitness, there is more time between beats for a few cells to fire prematurely, and for all of these reasons ectopic heart beats are more common, or certainly more commonly noticed, by people with a high level of fitness.

I grilled him some more on the effects of endurance sports on the heart, and again was reassured. He said that from a health point of view, I would get the same benefits from much more moderate, shorter periods of exercise, but didn’t see a significantly higher health risk from high-level endurance competition. He said that my heart muscles would not thicken significantly more with continued training. He spoke of the need to de-train properly when I “retire” from competitive racing, rather than a complete and immediate cessation. This could have detrimental effects, causing my heart muscles to turn to “jelly”. Not what I want.

He said that all of this would hopefully be backed up by an echocardiogram, which was scheduled for a couple of days later. He said that a nurse would carry out the procedure, and would be able to give me her opinion. She would then pass the results to him, and he promised he would phone me for another discussion.

So a few days later I was back in the hospital, lying on a bed with my top off, being jellied up by a humorous nurse. An echocardiogram takes about half an hour and involves being poked, prodded and rubbed by an ultrasonic probe. The jelly is applied to create a better “connection” between the probe and the body. A real-time image of the heart is then projected onto a computer screen, and detailed measurements and analyses can be carried out.

The probe occasionally makes noise, beeps, and transmits the whooshing, glugging sound of the heart doing its job. It was quite amazing. The nurse would tell me when it would make a noise, and what kind of noise it would make, I guess to stop any potential panic. Apart from when her pager went off. It was like in the movies, when someone is in intensive care, and all of a sudden the alarms start blaring, computers start beeping, and doctors and nurses appear from nowhere, galvanised into urgent and life-saving action. Her pager sounded exactly like this. Really loud, “BEEP BEEP BEEP BEEP BEEP BEEP….” For a split second it took me by surprise. But I was immediately reassured. “Don’t worry darling, you’re not dying, it’s just my pager!” I know that expectant mothers have ultrasound scans of their babies. I asked the nurse what would happen if she found a baby. “I hope I find a baby because if I do, we’ll be rich and famous…” Unfortunately, or fortunately, there was no baby…

The nurse’s impression of the echocardiogram was favourable, and she said she would pass the results to the cardiologist, who would phone me. They were as good as their word, and I had another lengthy discussion with the cardiologist. My heart muscle thickness was “in the upper range of acceptable.” If 1 was normal, and 1.3 was the upper limit of acceptable, mine was 1.2, which was pretty much “normal” for an endurance athlete. The echocardiogram had not shown up anything untoward, and the cardiologist was confident that I had a normal heart, with no problems and nothing to worry about. He was very confident in his diagnosis of harmless infrequent ectopic beats. I could continue training with no fear, push myself, go to the Alps, and carry on racing. This was great news.

Below is my heart, as shown in the echocardiogram. It's pretty amazing, and pretty taken for granted. Try making a fist, and squeezing it tight once or twice per second, even for a few minutes. It gets pretty tiring, pretty quickly. Try doing it for a lifetime. That's what the heart does...

 

The cardiologist was really thorough and I liked his attitude and approach. To leave no stone unturned, he suggested that I wear a 48-hour heart monitor in the hope that it would capture an ectopic heartbeat or two. This would allow them to be analysed in depth and absolutely confirmed as harmless. A 48-hour monitor involves having a few electrodes stuck to the skin, and carrying a small portable receiver box that captures the data over a 48-hour period. However, there was no time to do this 48-hour monitor before the Alps trip. The cardiologist was very confident that there were no problems and said he was happy for me to go and train hard, then have the 48-hour monitor done when I get back. His email report to me read as follows:

I really am quite happy with the result.

 

As we discussed on the 'phone I take a cut off of 1.3cm for the thickness of the left ventricular wall - yours is 1.2cm and so normal, especially for an athlete. The heart internal dimension is also within normal limits at 5.6cm, but again I would accept 5.8cm.

 

I note the comments about the RV appearing large, but this is subjective, appears OK to me and it works well.. There is also 'mild MR' (mitral regurgitation) but this is an extremely common finding with the sensitive equipment these days where some blood is seen to go back through the closed mitral valve, and it is of no consequence.
 

Again, putting the echo in the whole context of your symptoms I have no problems with you training and good luck with this.
 

I am of course very happy to go over this again in clinic when we have the results of the heart monitor too.

 

I'll have a few more questions for him, but having talked with him, and the nurse, and received this email, I'm satisfied there is nothing serious gong on. I’ve since done some reading up on ectopic heartbeats and have found people on various internet forums who have experienced exactly what I have felt, and who have also been investigated and given the same diagnosis and all-clear that I have been given. There seems to be a feeling that they can be brought on by a few things: caffeine, taurine. Too much sugar. Stress. High fitness and a low heart rate. Lack of sleep. Exercise. A change in fitness levels or exercise habits. Or they can happen for no reason at all. Most of these reasons are applicable to me. I was told that while wearing the 48-hour monitor I was to try to induce the ectopic beats. So maybe I’ll stop sleeping and start drinking coke…

 

A few quotes from various websites and internet forums that I've come across and can completely relate to:
 

• It's common in trained athletes and, especially if only occurring at rest, harmless. Usually felt as a 'flutter' (the early beat) and then a 'thump' (the next 'normal' beat that is more forceful than usual as the heart has had time to fill with blood during the time it needs to re-polarise after the early beat). As you say, caffeine can exacerbate them as can viral illnesses, hangovers and general tiredness. The slower your resting heart rate, the more likely you are to get them - all heart muscle cells are connected electrically therefore if one cell fires off, the whole heart beats. The sino-atrial node (pacemaker) has the fastest intrinsic rate and normal heart beats originate there but the slower it gets, the more likely other heart muscle cells are to depolarise (fire off) before it and cause an early beat. Studies have been done looking at people with frequent early beats and structurally normal hearts and there is no increase in risk compared to people who do not get them.

• ...you have the impression you miss a beat, then a next one is stronger, and your stomach feels exactly like when you're flying and the plane drops for a second or so...
• Happens to me once every hour or two when I start getting into exceptional shape. It's to the point now that it's become an indicator of when I'm reaching top form. Only happens when I'm not working out though.
• The feeling is very distinct, definitely like a 1-2 second free-fall followed by a super hard double-the-strength beat that is easy to hear internally.
• No worries. You have had the work-up and you know the cause. My resting heartrate in my 20's and 30's was about 36 so anytime I had caffeine I got the thump fest. Really unnerving, especially as a medical student rotating through cardiology and watching some of the patients die from fatal arrhythmias. Worse at night if you lay on your left side because then there is no way not to notice and also when sitting still quietly doing whatever. As an athlete you likely have sinus bradycardia and a larger more powerful contraction which really heightens your sense of what it going on. Now in my early 50's, my resting heartrate is 44 and the caffeine no longer has the same effect. As long as you are not having prolonged episodes, I would try to forget about it. Your heart will probably last your lifetime. ;-)
• That's when your heart beats out of synch for like 1-2 beats (one really slow, then a pause, then two fast ones or something similar), right? That happens to me sometimes (sometimes once a month, sometimes once a day). I got an echocardio and an EKG, there is nothing to worry about because it is something that is pretty common.
• Try cutting out the sweetener Aspartame from your diet. The little blighter crops up in all kinds of food.
• Caffeine, changes in workout routine, etc., all can be associated with some ectopy. You've been checked and cleared. The only time I'd get concerned is if you got into an atrial fibrillation rhythm, where your HR is constantly erratic for a long period of time.
• I go through periods of getting these when I'm resting. For me I think it coincides with my cardiac fitness making rapid shifts up or down - say I mostly get them when I stop training for a while, or bump my training back up, as though they are caused by my system readjusting to the change in fitness. Therefore, nowadays when I get this when I'm training heavily I actually take it as a positive sign that the training is working!  
• Anyway, don't understimate stress and how it might impact your symptoms, even though you may not realized you're not stressed. It may be that you're not relaxing. I went for three years thinking it had a completely physical origin.

 

I’m a lot happier now than I was a few weeks ago, and I do feel a bit sharper too. Hopefully ten days in the Alps next week will do me a lot of good, and then after that I’ll have one more tough week of training followed by a two-week taper before Ironman Wales. I really hope I go to Ironman Wales and deliver a performance that I’m happy with…