Are You Fit To Race Triathlons?

Being a physically fit triathlete isn’t a guarantee of immunity from a life-threatening heart episode. Rattled by news of racer deaths in triathlons, a concerned age-group triathlete took a proactive approach to understanding his heart health so he can race in confidence. Learn how you can do the same.

Hill sprints were never my idea of a fun workout. Running all-out up a 17 percent grade on a treadmill with a neoprene mask strapped to my face is a whole other level of suffering.

As my feet slap the treadmill belt, my breath rasps in and out through a plastic vent, like Darth Vader having an asthma attack. A white tube juts from the vent, tugging at my head with each step. Ten slender wires emerge from a pouch at my waist and stick to my chest like little leeches. The machine tilts upward a bit more, and I lunge to keep up, fighting the leaden feeling spreading down my legs.

“Give it all you’ve got. Come on now,” urges Dr. Aaron Baggish, as he stands to the side, glancing from me to a pair of computer screens.

With any luck, these minutes of misery will make for years of happy training. If the test doesn’t kill me first.

My journey to this treadmill at Boston’s Massachusetts General Hospital started four months earlier, the day of the age-group national championships in Burlington, Vt., where I live. Before squeezing into my wetsuit, I called my two kids and my wife. I told them each I loved them and needed good-luck wishes. I didn’t say what else was on my mind: that I hoped to make it out of the water alive.

The start of a race had taken on a new kind of anxiety as I read sporadic reports of fellow triathletes dying—at least 13 in the U.S. in 2012. Shortly after crossing the finish line in Burlington, my racing high was tempered by news of another casualty. Fifty-three-year-old Richard Angelo was pulled from Lake Champlain an hour before my wave started.

Maybe that could have been me, I thought in the following weeks. Was there anything I could do to increase the odds I’d come home after a race? I set out to find what medical experts would say to that question.

For Baggish, the sudden, unexpected death of an athlete is a personal thing. At 24, while trying to qualify for the Olympic marathon trials, he stood at a track in Boulder, Colo., waiting for a buddy to show up for a workout. His friend never arrived. He fell dead while running to the track, the victim of an undiagnosed genetic heart problem.

That incident helped inspire Baggish to become a cardiologist, and to dedicate himself to finding heart problems that could cut short an athlete’s life. Which was how I came to be sitting in his Cardiovascular Performance Lab, a windowless room barely big enough to hold a rowing machine, treadmill, stationary bicycle and computer terminal. This is where athletes go when Baggish, now 37, wants to see their hearts in action.

But first, he started with some simple questions. Has anyone in my family had heart problems? Have any of them died at an early age? An assistant checked my blood pressure, which was normal. A doctor’s job resembles detective work, piecing together clues to figure out what’s happening inside a patient. This part is more old-fashioned Sherlock Holmes than high-tech CSI—just a stethoscope, a blood pressure cuff and lots of nosy questions. It’s also the first and most important step athletes can take.

All the doctors I spoke to say that, before training, athletes should get a physical exam and discuss their plans with a physician, preferably one experienced in working with athletes. This simple visit is the centerpiece of recommendations from the American Heart Association. It tops the list of advice issued in October by a group that reviewed triathlon deaths for USA Triathlon, the sport’s governing body in the U.S. And it’s something many athletes don’t do.

“The common misconception is that being a fit athlete provides some kind of immunity,” says Baggish. “And that is not the case.”

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I fit unnervingly well into the profile of endurance athletes who’ve died during these races. A lifelong athlete, I’ve competed in triathlons for more than a decade, usually finishing near the front of my age group, but well behind the race winner. At 42, I’m the average age of distance runners who had cardiac arrests while racing, according to a 2012 study led by Baggish and published in The New England Journal of Medicine. People between 40 and 60 accounted for slightly more than half of the 45 triathlon deaths examined by USA Triathlon.

After hovering between three and eight per year, the triathlon death toll jumped to at least 12 in the U.S. in 2011. The death rate is one in 76,000, according to the USA Triathlon study. And then there’s this puzzling twist: It usually happens during the swim.

A leading theory is that the intense effort of racing, the stress of swimming amid flailing arms and legs, and some underlying heart problem combine to make the heart go haywire and start beating wildly. From there, it’s easy to imagine the heart stopping, or the swimmer passing out and drowning, before rescuers can perform CPR. Baggish’s study found that most distance runners who suffered cardiac arrest during a race had abnormal heart muscles or clogged arteries, a common ailment for the middle-aged.

Another suspect is SIPE, or swimming-induced pulmonary edema, a rare lung problem in which high blood pressure suddenly floods a swimmer’s lungs with fluid. Dr. Richard Moon, a Duke University anesthesiologist who studied the issue for the Navy, said it would explain why triathletes are dying mostly during the swim. There’s no test for SIPE. But it might be linked to chronic high blood pressure, poorly controlled asthma or heart disease, Moon says. Symptoms like getting short of breath during a swim or coughing up pink, blood-flecked spit also warrant a trip to the doctor.

But Dr. Charles Miller, chair of the Department of Biomedical Sciences at Texas Tech University, doubts that SIPE is at the root of these deaths. A triathlete and runner, he suffered a SIPE attack while water jogging in a pool. Being an epidemiologist, he wondered whether it was killing triathletes. He concluded it was unlikely, since SIPE is very rarely fatal, and there’s no case he could find where a dead triathlete had previously been diagnosed with SIPE.

“There may be a few of those deaths that are SIPE related. But I’d be surprised if it was most of them,” he says. “I’d be really surprised.”

Baggish, who has competed in triathlons up to half-iron distance, thinks some of the deaths are panicked swimmers drowning. But others dismiss that, particularly since a number of the deaths involved strong, experienced triathletes.

When an athlete comes to Baggish, chances are he or she will eventually wind up on the treadmill. Usually they’ve been sent by another doctor with concerns. Sometimes it’s just a patient looking for reassurance—the “worried well.”

Either way, Baggish considers a stress test the best way to see what happens to a heart during competition. A standard electrocardiogram, or EKG, which measures the heart’s electrical signals while a person is sitting still, can catch genetic abnormalities or scars from an old heart attack. But it’s blind to things like hardened arteries. Enter the stress test—an EKG combined with a potentially nasty little workout.

“I exercise all my patients,” Baggish says. “There are people who will disagree with the approach, but I feel strongly it’s the best way to determine whether an athlete is at risk.”

Baggish is part of what I’ll call the “more is better” camp. Then there’s the other side, which warns that more can just mean expensive confusion. The American Heart Association recommends only a physical exam and interview for athletes under 40, unless that visit turns up something worrisome. For athletes over 40, it advises a one-time EKG. However, a leading group of European cardiologists and the International Olympic Committee have called for EKG tests on young athletes to catch genetic problems like hypertrophic cardiomyopathy, a thickening of the heart muscle.

The reluctance for more testing in the U.S. is partly because EKG’s aren’t terribly accurate—they can miss a lot of problems and cause false alarms. Also, a basic EKG for every high school and college athlete would cost $2 billion a year. Stress tests, meanwhile, are only for those with warning signs or a worrisome family history, says the Heart Association.

“There’s no evidence right now that routine stress testing on people without symptoms does anything,” says Dr. John Mandrola, a bike racer and former triathlete in Louisville, Ky., whose specialty is the heart’s electrical system. He cautioned that false alarms can lead to further tests—like inserting a catheter into the heart—that come with their own risks.

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“It’s extremely unlikely that a 42-year-old person with no risk factors, or even one risk factor, has an undiagnosed disease,” he says.

Which left me, the 42-year-old in question, wondering what to do. The exam with my regular doctor found nothing to worry about. He referred me for a standard EKG, which probably wouldn’t tell me much. But I wavered after talking to people like Dr. Larry Creswell, a triathlete and cardiac surgeon at the University of Mississippi who helped head the USA Triathlon death study.

(I should mention here that all the doctors I talked to endorsed the Heart Association recommendations as a general policy, and none thought athletes should be required to do more testing before competing.)

But if a friend asked what tests to undergo to make sure he was safe, Creswell had his own formula: an EKG and an echocardiogram, an ultrasound of the heart that can help catch defects like flawed heart valves. But it comes at a hefty price—roughly $1,600 for an echocardiogram at his hospital for those whose insurance won’t cover it.

“You have to decide if it’s worth investing that,” he says. “That’s what I tell people who say, ‘What can I do if I’m worried that I’m going to be the one-in-75,000?’”

My conversation with Baggish finally decided it. He assured me that a false positive was unlikely in the hands of a doctor who works with athletes. And if insurance wouldn’t pay for it, his lab offered the stress test for $350, with the added bonus that I could get some useful performance measurements, including VO₂max and anaerobic threshold. What triathlete can resist the lure of more data?

When the test started, I naively wondered if it would be too easy. I jogged along on the treadmill at 10 minutes per mile. Miranda Contursi, an exercise physiologist, held up a chart with phrases ranging from “rest” to “maximal” and asked how I felt. I casually pointed to “easy.” It was the last time I would say that.

The front of the treadmill began inching up half a degree every 15 seconds. Unlike a typical stress test, which involves a moderate workout, this one was designed for athletes. Translation: I would run to the edge of collapsing. To top it off, my oxygen intake would be measured with the facemask contraption. Baggish had casually mentioned I’d probably make it 20 or 22 minutes. I took that as my target.

At around 14 minutes, I started breathing harder, and my legs began straining. I pointed to “moderate” on the chart. Two minutes later, things were coming apart. I started panting. Sweat and snot were pooling inside the mask strapped around my head. A small fire was kindling in my legs. My casual stride had turned into a foot-hammering rush. “Nice job,” Contursi cheerfully declared.

In another minute I was in survival mode, desperately trying to reach 18 minutes without a humiliating stumble and bellyflop onto the whirring belt. Seconds after my new finish line, I flailed one hand into the air and surrendered. Contursi shut down the treadmill. I had a new respect for 10-minute miles.

After my cool-down, Baggish scanned graphs on the computer and flipped through EKG printouts showing lines jumping up and down like the contours of a mountain stage in the Tour de France. He picked out high spikes on one reading. That might alarm a doctor unfamiliar with jocks, he said. But it’s only a sign of heart muscle growth common in endurance athletes. Finally, he delivered the verdict.

“Everything really looks perfectly normal,” he said.

A weight I hadn’t known I was carrying suddenly lightened. I’d expected that result all along, but felt reassured by those cryptic graphs and Baggish’s experienced judgment.

Risk does funny things to our heads. I was probably in more danger driving from my home in Vermont to Boston than I will ever be in a triathlon. Yet I got behind the wheel without a second thought. If the tests had come back with a problem, it would have forced me to confront the question of how much risk is too much. Baggish does that all the time with athletes. He calls it “risk stratification.” It might mean dialing back the intensity and giving up that age-group podium, or finding a less strenuous sport.

We “risk stratify” all the time. None of those tests guarantee my safety. And I, like many, have decided that the adrenaline surge when the horn sounds, the rush of speeding down a straightaway on the bike, the thrill of finding one more gear in my legs in the last mile, is worth it. But now, before suiting up for the next race, at least I can reassure my family I’ve done what I can to make sure I’ll come home.

RELATED – Conviction: Deaths In Triathlon

Are you fit to race?

Inform yourself to protect yourself.

Physical exam and interview
Go if you haven’t before, or if you have symptoms such as breathlessness during or after exercise, heart palpitations, fainting, chest pain or an unexplained drop in performance.
Pros: Alerts doctors to red flags warranting further testing.
Cons: Won’t pick up some “asymptomatic” heart problems.

Electrocardiogram (EKG)
The American Heart Association only recommends using an EKG if a checkup raises alarms, or as a one-time check for athletes over 40, but it can also can find congenital heart problems, the most common cause of sudden death in young athletes.
Pros: Relatively cheap and simple ($25–$75), it can find heart defects and genetic disorders.
Cons: Prone to false alarms, particularly if a doctor is unaccustomed to working with endurance athletes, whose hearts have subtle differences. Can’t detect hardened arteries, a common ailment in older athletes.

Echocardiogram
An ultrasound of the heart. Can show physical anomalies like thickened heart muscles or the sort of valve defect that ended the career of Ironman world champion Normann Stadler.
Pros: Catches some deformities that an EKG won’t.
Cons: Expensive ($99 to $1,600). Won’t show hardened arteries and could miss things that only show up during exercise.

Stress test
An EKG combined with a workout. An effective way to look for heart problems during exercise, including hardened arteries. The Heart Association recommends it for masters athletes (men over 40, women over 50) when an exam finds at least one risk factor.
Pros: A relatively nonintrusive test, and one of the best ways to see the heart in action.
Cons: Expensive ($100 to $1,000). Insurance might not cover it unless a doctor finds a good reason. Doctors debate whether it’s useful in a patient with no signs of a problem.

Source: Cost estimates from Dr. Christine Lawless, co-chair of the American College of Cardiology Sports and Exercise Cardiology Council. Cost estimates vary based on type of health center.

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– Conviction: Deaths In Triathlon
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– USA Triathlon Releases Fatality Incidents Study
– Pros, Age-Groupers React To Ironman SwimSmart
– WTC CEO Andrew Messick On Ironman Swim Changes
– Ironman Announces SwimSmart Initiative In North America

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