My intention had been to continue my blog series on the biggest innovations in heart health over the last decade today, but I must push that to next week. The reason? I’ve been on call all this week and it has been rather extraordinary, such that I feel I must write on that instead. I often like to use real life case studies in my blogs, to give readers a real sense of ‘front line’ heart care. A week on call often serves up some good stories, as over a seven day period the number of patients encountered is huge. And so it was when I pitched up last Monday. You may or may not know but last weekend was the Bournemouth half marathon. It’s not unusual at all to get one or two people admitted to hospital with this and that around the time of an endurance race, but I can’t ever recall a situation such as this week.
On coronary care alone I looked after 4 patients, and came across another 4 patients on other wards, including the intensive care unit. I want to say at the outset I’m still very much in favour of people running, it is fantastic exercise and great for mental health, so please don’t let what remain rare events put you off!! I will obviously obscure any identifiable details, but would like to tell their stories. The first chap I came across was several years younger than me (I’m 47) which always makes me double check the date of birth! He had had a full blown heart attack, and his only conventional risk factor was a modestly raised cholesterol. He had done plenty of training for the run, with no symptoms beforehand at all.
It is the case that often the extra effort involved on race day leads to a higher incidence of heart attacks, but nevertheless this is rare in a person of that age. So what is going on behind the scenes? The most likely explanation is a genetic predisposition. For years doctors have perhaps thought of cholesterol too much in isolation, but human biology is rarely so simple. Why does one person with raised cholesterol have a heart attack, and the next does not, if other risk factors like smoking, obesity, diabetes and so on are the same?
The key message is simple: heart risk is personal. Two people can have the same cholesterol level but very different chances of heart disease depending on their genetic background. As genetic testing becomes more accessible, combining it with traditional cholesterol checks could allow for more individualised prevention — helping identify who might benefit from earlier lifestyle changes or medication. In this week’s research video, I discuss a trial published this year on exactly this, and how the latest genetic tests can help us determine an individual’s risk. This cutting edge science is not routinely available in the UK, but following some productive meetings last week, I will shortly in a position to offer this gene test to my patients. More on this in the next few weeks; stay tuned.
Another patient I was asked to see was even younger, in their early 30s, and the question being asked was whether he too had a heart attack. That had been raised because of a rather abnormal ECG (paper tracing of the heart) and a high blood test result for troponin. Troponin is a marker for heart damage, so goes up with heart attacks but also some other things. It is commonly elevated in people with kidney disease. In this poor person’s case, the issue was something called rhabdomyolysis. This is a serious condition where strenuous exercise (often with dehydration and heat stress) can lead to intense muscle breakdown, in turn releasing muscle proteins and electrolytes into the bloodstream. This can cause acute kidney failure, as it had in this case, which in turn caused the ECG changes and troponin blood test. Fortunately with treatment he is making a good recovery.
For me though, the most interesting case was a man of my age, a very good sportsman with a long history of athletic endeavours, who presented to hospital as his heart rate wouldn’t return to normal after the race. In A&E, he was found to be in ventricular tachycardia (VT), a potentially fatal heart rhythm, abnormality. This required an electric shock to be delivered (defibrillation) to restore normal heart rhythm! I was pretty sure this would turn out to be an underlying heart attack, much like patient No. 1, but in this case his arteries were completely normal. I arranged for advanced scans of his heart, and long story short, the diagnosis was arrhythmogenic right ventricular cardiomyopathy, or ARVC. This is a rare inherited heart condition which in its worse condition can be fatal. You may remember former England cricketer James Taylor, who was forced to retire from professional cricket aged just 26 in 2016 having been diagnosed with ARVC. Sadly it is one of the only heart conditions in which we advise against strenuous exercise, and as such, my patients days of endurance athletics are over. It breaks my own heart having these conversations with patients as I love exercise so much myself. However, there is definitely a middle ground to be had, and with careful planning and expert advice a healthy lifestyle can be maintained.
In total I’m aware of 8 patients admitted after the race with heart issues, and I hope you’ve found these three stories interesting and informative. As I said at the outset, this should not put you off exercise provided you’ve not been told by a doctor to refrain. If you would like an assessment on safety to exercise, please hit reply or contact me using the details below. I have done some intensive workouts this week, and always practice what I preach!