Quick Questions: Athletes and Heart Health

Podcast Transcript

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Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Tamanna Singh, MD:

Hi, everyone. My name is Dr. Tamanna Singh. I am the director of the Sports Cardiology Center at Cleveland Clinic, as well as one of the founders and co-directors of our Women's Integrated Sports, Exercise and Research Center, WISER. I'm really excited to talk to you guys about heart health as athletes. I'll be answering some of the most common questions. I'm sure there are many more, but we'll try to get to some of the high yield ones today. So, what does heart health really mean for athletes and highly active individuals? I think heart health for athletes is very similar to what heart health means for our general population. The things that I take a look at when I'm considering cardiovascular risk stratification for athletes are common things like high blood pressure, elevated cholesterol, or abnormally high bad cholesterol, a.k.a., LDL, abnormal blood sugar control, certainly taking a look at body composition changes, even smoking history and more.

And so, that being said, being physically fit and active while great is not always protective against heart disease. I've seen a number of athletes who have some of these common cardiovascular risk factors. So, it's really important to make sure that you know your personal medical history, as well as your family history, so that we can address any risk and keep it as low as possible moving forward. When it comes to things that you can do to help to prevent some of these cardiovascular risks, exercise is certainly a piece of the puzzle. And it really doesn't matter what style of exercise you do. Strength training is equally as important as getting in that regular cardio, whether it be something steady state and conversational or even incorporation of some higher intensity intervals. Your heart really doesn't care what you do. It could be the bike, it could be a run, it could be the elliptical, it could be rowing.

There are so many activities that can get your heart rate up. And like I mentioned, all activity really does help to keep our cardiovascular risk very low. When it comes to some of the most common heart conditions that we've seen in athletes, they really do, one, run the gamut. We basically split athletes into two big groups, typically those who are younger, so less than 35 years of age, and those who are a little bit older or considered masters athletes, above 35 to 40 years of age. In our younger athletes, oftentimes we see cardiac problems that are associated with things that they were born with. What we describe as congenital abnormalities. Sometimes young athletes may have issues with the actual heart muscle itself, what we describe as cardiomyopathy. And sometimes younger athletes might even have some abnormalities in how their heart vessels or coronary arteries are aligned.

Sometimes that anatomy may be what we describe as anomalous and require treatment. Younger athletes may also have some abnormalities in their electrical system of the heart that can lead to increased risk of what we describe as sudden cardiac arrest or death, when the electrical activity of the heart stops, which is an immediate urgent need for resuscitation with CPR, as well as an onsite defibrillator. And our older athletes, those who are over 35 to 40, though the caveat is I don't think people who are 35 are older. But in these individuals, that's where our cardiac risk really is important to detect. And I'm talking about things like blood pressure, cholesterol management, body composition, and more. In these types of athletes, the most common cause of cardiac arrest and death tends to be associated to run-of-the-mill heart disease. So, athletes really are not immune to developing cholesterol plaque accumulation in their heart vessels or their coronary arteries.

With that being said, it's extremely important when we're managing our athletes and talking to them about nutrition, certainly their own personal and family health history, that we make sure that our nutrition really incorporates really low amounts of saturated fat, namely animal products, like dairy, egg yolks, cheeses and more. And really focus on maintaining a good balance of healthy proteins, healthy unsaturated fats, like nuts and seeds and plant-based oils, and a healthy dose of carbohydrates that typically can be in line with the amount of training that you're doing. To really see how much cholesterol plaque you have in your vessels, oftentimes cardiologists like me will proceed with additional imaging. Sometimes we'll get tests called calcium scores, where we can look at the amount of calcified plaque and heart vessels or coronary CT angiograms, which allows for us to get a good look at not just calcified, but also non-calcified plaque.

Oftentimes, that soft, squishy, non-calcified plaque is the one that is more inflammatory. So, again, just to break it down. If you're a younger athlete, less than 35, the things that I'm always looking for are cardiac issues that you potentially may have been born with. And if you're on the older side and still training aggressively, we really want to make sure we do our due diligence to look for and address any heart disease that can be found within your coronary arteries. Additional tests that might be helpful and truly only if they're indicated, are recommended depending upon whether or not athletes may have symptoms. Sometimes I see athletes who tell me, "Hey, Doc, my pace is a little slower than maybe about three to four months ago and I can't really explain why." Or I might have patients who tell me that they have chest discomfort with exercise that goes away when they rest.

Sometimes I have athletes who tell me that they feel like they're going to pass out maybe during or after exercise. And finally, I have a number of individuals who might say that their heart is racing really, really fast, sometimes when they're doing nothing and sometimes with activity. All of these are red flag symptoms that help me decide how we can further determine what the diagnosis might be for their issues. And this leads me into describing some of the testing that we might want to move forward with. One of the most common tests that we do is called an electrocardiogram. This is kind of like a 10-second snapshot of your heart rate and your heart rhythm. And sometimes the patterns that we see on EKGs may actually give us some insight into what the heart looks like. But to really get a good sense of what the heart looks like and what the function is like, we can reach for a modality called an echocardiogram, which is basically an ultrasound of the heart.

We can get a lot of information from this study. We can take a look at how strong your heart is or potentially how weak it is. We can look at valves, which are structures that sit between chambers of the heart and between the lungs, as well as the biggest vessel of your body, the aorta. We can look at aortic dimensions and much, much more. Both EKGs, echocardiograms, as well as CTs and MRIs of the heart are great ways to look at structural things that are related to your cardiovascular anatomy. But if I have individuals who are specifically symptomatic with exercise, then my job is to exercise you in a safe space, which is our exercise lab. And these tests are called stress tests, something that some of you may be familiar with. Stress tests come in all different sizes and flavors, but they all will include an electrocardiogram portion, which is basically looking at the heart rhythm and rate while you're exercising.

And sometimes stress tests may have an imaging component to them. Either pair an EKG with echocardiographic imaging or even potentially nuclear imaging, which is a great way for us to get a sense of what blood flow looks like to your heart muscle when you're exercising compared to your resting. All of these tests together really give us an outline and help us figure out what's going on and what is the cause for some of these cardiac symptoms that I've described. When it comes to figuring out whether or not you need urgent or emergent attention, I really say trust your gut. If you're having sudden onset chest pressure, if you've passed out, if you can't catch your breath, if you feel like something is wrong, ask for help and come and seek it with one of us. If you are someone, potentially a bystander or a spectator maybe at a race or at a training run, or a training event, and you see someone collapse near you, please be sure to start CPR immediately. And get your hands on an AED or an external defibrillator to see if that individual can be resuscitated.

The less time that we have between an individual going down and getting defibrillated, the more likely that individual may recover and their heart muscle function will recover. If you are not trained in CPR or you do not know how to use a defibrillator, I encourage you to seek out some of the community resources, where you'll be able to find some training sessions to give yourselves the skills to help save a life.

We're going to steer into a little bit of a different direction and talk a little bit about one of my favorite topics, wearables. A lot of my athletes love to track their fitness, whether it be with specific ecosystems associated to their smartwatches or potentially chest drops or arm straps that give them heart rate data. Wearable devices can be really helpful particularly for training. And even from a cardiac lens, they can help me figure out when individuals are having symptoms and whether or not their symptoms are truly correlating to abnormalities, specifically in heart rate.

I find that wearables are most helpful for heart rate and sometimes abnormal rhythms, like atrial fibrillation, particularly given all of the advances that our technology is making. So, if you have a smartwatch or if you wear a heart rate monitor and let's say you're someone who's got a lot of heart racing episodes, share that data with someone like me. And we can actually parcel out through your training activity when you are having those episodes, whether they correlated to your symptoms and potentially even come up with a diagnosis right there at that visit. The one thing I will say about wearables is trends are really much more important than single data points. Sometimes some athletes are concerned that they've had a heart rate of 39 beats per minute or maybe a heart rate that's really high, at 150 beats per minute, and they don't know what to do with that isolated data point.

So, I really encourage you guys to look for the trends in data, not so much the specific point, because trends will actually give us more of a temporal assessment of what's been going on with respect to how you feel and potentially any symptoms. I think after this discussion, one of the key takeaways that I'd like for all of you to take is exercise is truly incredibly helpful. We know that exercise helps to reduce our cardiovascular risk. And I really want all of you to get yourselves moving in whatever way you enjoy the most. But even if we move and are really active and are really healthy, some of the things that we can't control are our genetic and our family history. And sometimes some of the food that we consume or some of the lifestyle factors that we have, which might be stress or anxiety or high workloads, sometimes those things that we may not have as much control over can impact our cardiovascular health.

It's really important to either start with a cardiologist or even your primary care doctor and take a look at what's under the engine. Get a sense of what your blood pressures are. Get some regular labs checked. I always recommend getting a lipid panel, checking something called a lipoprotein little A, which gives us insight as to whether cholesterol abnormalities might be related to genetics or your family history. Get your Apolipoprotein B checked, which is also an independent cardiovascular risk factor associated with increased risk. Sometimes for my younger athletes or individuals who are feeling really tired, I'll check things like vitamin B12, vitamin D and iron studies. I'll also check people's blood sugar control with a hemoglobin A1C, a great barometer for how well your blood sugar has been controlled over a three-month period.

All of these are just examples of blood work or lab tests that might be beneficial for you and your provider to discuss, to make sure your cardiovascular risk stays as low as possible. Remember, sometimes ignorance really isn't bliss. I have a lot of individuals who feel like, "Hey, I feel just fine, so why do I really need to go through any of this or check under the hood?" And what I'll say is cardiovascular risk or cardiovascular disease, particularly if we can reduce all of those risk factors, we can reduce our risk by 80%, which is phenomenal. So, the more we know about ourselves, the more we know about our family history, the better off we are in reducing our risk over time. And that gives us more time to get out there and go for that run or go for that ride and stay healthy for as long as possible.

Thank you so much for listening to Love Your Heart. Have a wonderful day.

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