Cardiac arrest in marathons and triathlons

Your Heart Health in a Heartbeat – Episode 6


Cardiac arrest during marathons: 10 facts to consider.

Study of triathlon deaths concludes more screening is needed.

Interesting research studies from the American College of Cardiology 2016 meeting.


Hello everyone,

There has been bad news coming from the marathon and triathlon communities regarding cardiac deaths during these events.  At the London marathon, a middle aged man suffered a cardiac arrest, and in Canada, a few days ago, a middle-aged woman also had a cardiac arrest and died during the swim portion of a triathlon.

So I thought I would take a few minutes today to go over what we know about cardiac arrest at these endurance events, and then go over some new recommendations for screening that were proposed at a recent meeting of the American College of Cardiology.

So first, the marathons.  A few years ago, an important paper was published that looked at cardiac arrests occurring during marathons over a 10-year period.  Let me give you five highlights from that paper:

First, cardiac arrest is much more common in men than in women, by a factor of 9-to-1.

Second, the average age was 43, but the age range was wide, from 22 to 65 years of age

Third, the frequency has been increasing over the years.  That is likely because more people are participating in these kinds of events, and some of the participants are older than in the past.

Fourth, most cardiac arrests occur in the last third of a marathon.  That’s probably because of strain and exhaustion as contributing factors, or possibly electrolyte shifts.  The cardiac arrest that occurred in the London marathon occurred near the end of the race.

Fifth, in most cases, the victims were found to have had a pre-existing heart condition they were unaware of, most commonly a disease of the heart muscle, called cardiomyopathy, or a disease of the coronary arteries.

I wrote a more complete blog post on this topic and I will link to it in the show notes on the website.

Now, as far as triathlon events are concerned, a study was presented a few weeks ago at the American College of Cardiology’s scientific meeting.  The study was led by Dr. Larry Creswell, a heart surgeon who is also a triathlete and has written extensively on cardiac complications in athletes.

The study is not published yet, but I can summarize the main findings as they were reported:  First, the demographics were similar to those of the marathon study: average age in the mid 40’s and mostly men.  Secondly, most deaths occurred during the swim portion of the event.  Thirdly, like in the marathon study, many of the cardiac arrest cases had an identifiable pre-existing condition that could have been detected by screening.  On the basis of those findings, the investigator recommended that middle-aged should consider heart screening before these events.

That said, we should add that how you do the screening matters.  If you are going to screen with just an ECG or a routine physical, that may not be enough to pick up the conditions we’re interested in that might lead to cardiac arrest.  It is important that the screening be thorough.

Blood pressure and exercise

Your Heart Health in a Heartbeat – Episode 5

Document mentioned: 

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension


Hello everyone and thank you for joining me.

I’m Dr. Accad, medical director of Athletic Heart of San Francisco, and today I would like to talk about high blood pressure in relationship to exercise.  I am doing this in light of a document recently published jointly by the American College of Cardiology and American Heart Association that makes some recommendations for competitive athletes who have blood pressure concerns.Read more

535 kids screened!

Again, Athletic Heart SF is delighted to have participated in a screening event for school kids age 12-18 that took place on January 26, 2016, at Sacred Heart High School in Menlo Park.  The event was organized by Via Heart Project, and the kids also received instructions in basic CPR.

A total of 535 kids were screened, a 3 were found to have conditions that put them at risk of serious cardiac complications.  Others were also found to have some structural anomalies of the heart or aorta that would need further follow-up.

If you think your school district could benefit from a screening and would like to get involved, I encourage you to contact the non-profit Via Heart Project organization.  Also, don’t forget that the availability of AED is essential to increase survival rates in case of cardiac arrest.  If your local school is not properly equipped, Via Heart also helps with that.

The proper management of high blood pressure


If you have a high blood pressure concern, or you are on treatment for hypertension, you may wish to watch this video.  The transcripts are below, but let me also point you to this medical journal article, called On Redefining Hypertension.   I wrote it with my colleague Dr. Herbert Fred and you may find it informative.



Hello everyone

Today I’d like to talk about high blood pressure management, because I think this is one area where there is a lot of confusion, even among doctors.  Just in the last couple of years, there have been studies and recommendations that conflict with each other about what constitutes high blood pressure, how to treat it, and so forth.

I will talk briefly about what high blood pressure is, why there is confusion about it, and what I think is the proper way to deal with people who have blood pressure concerns.Read more

Water intoxication during exercise and athletic activities

Your heart health in a heartbeat _ Episode 3


Hello Everyone,

Today I’d like to talk about a topic that has nothing to do with heart disease, but one which I think should be of interest to athletes and to people who do intense exercise and sports.  The topic is “water intoxication.”

I bring that up because a young man came to Athletic Heart SF just the other day to be evaluated. He had had really bad symptoms during an intense workout, and there was a concern it might be his heart, but we figured out that the most likely cause of his symptoms was water intoxication.Read more

Why are screening tests controversial?

Your heart health in a heartbeat – Episode 2

Mammograms, PSA tests, heart scans, lung scans are all subject of debate and controversy.  Why is that?  Join me as I clarify the reason why screening should not be viewed only from the perspective of public health,


Today, I’d like to talk about screening tests in general and why there seems to be so much debate and confusion about them.  It seems that every other week there is a new report in the media raising doubt about the value of this screening test or that screening test, whether it’s mammography, the PSA test for prostate cancer, colonoscopy, heart scans, or what have you.  And you hear one group of people advising one way and another advising another way, and it’s very confusing.

So how do we make sense of that?Read more

Are statin drugs over-prescribed?

Your heart health in a heartbeat – Episode 1

If your cholesterol is high, should you immediately start lifelong medication?  Join me as I discuss a new study which addresses this important question.

Link to the study discussed in this episode:

Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines

Related blog post about the heart scan:

The heart scan as a “mammogram of the heart”



Aortic aneurysms in simple terms


Please note: this article is for general information only and should not be taken as specific medical advice. Should you have any symptoms or concerns, please seek medical attention or contact us for further evaluation. If you feel you are having a medical emergency, contact 9-1-1 immediately.
Case report (part 1 – diagnosis)

A 57-tear-old man made an appointment for an Athletic Heart SF screening.  He was feeling well.  His exercise routine included lifting weights, but also doing some light treadmill activity at the gym several times a week.

He played competitive football and basketball in high school, and played various other sports throughout his life.  He played full court basketball until 4 years ago but had to stop due to mild knee arthritis.  He had been coaching sports for many years.  For the last 1-2 years, he had noted some mild shortness of breath walking uphill.

He had no prior history of heart disease.  He was advised by his primary care physician to take blood pressure and cholesterol-lowering medications, but he declined.  He had no other chronic illnesses except for mild knee arthritis and occasional tension headaches.  He considered himself in good overall health.

During the Athletic Heart SF screening, we confirmed that his blood pressure was elevated.  We also discovered a significant aneurysm of the ascending aorta.  Left undetected and unattended, this aneurysm could rupture and lead to very serious complications: stroke, heart attack, paralysis, kidney failure, or death.Read more

Podcast interview with Sami Karam


I had the pleasure of being interviewed by Sami Karam, the editor of Populyst, an economics and demographics blog and podcast.  Sami heard about Athletic Heart of San Francisco and decided to devote a show to the topic of heart screens.  We covered a lot of ground, but the focus was mainly on detection of coronary disease and on contrasting the early detection strategy to the strategy of managing risk factors.  I hope you will find our conversation informative.  To listen to the podcast, simply click on the play button below or on this link.


The echocardiogram: seeing with sounds!


Ultrasound technology is not exactly new, but it never ceases to amaze me.

First developed in the 1950’s, medical ultrasound technology uses the fact that different tissues and fluids in the body reflect sound waves differently.  If an ultrasound source is applied over the chest, the sound will be reflected back from different parts of the heart in a way that can be analyzed to reconstruct an image of the heart in real time.

"Ventricular Septal Defect". Licensed under Public Domain via Wikimedia Commons.

Licensed under Public Domain via Wikimedia Commons.

Because of the clarity and reliability of the image produced, echocardiography has become an indispensable tool of cardiac diagnosis and has allowed doctors to “see” directly what they previously had to imagine, deduce, or guess: the size of the heart chambers, the pumping strength of the heart muscle, the health and function of the heart valves, the presence of fluid build up around the heart, the size of the aorta and other major vessels, and many other important cardiovascular features.  Having all this information at the tip of our fingers would have been unimaginable to cardiologists of a generation or two ago.

What’s more, the procedure itself—as far as the patient is concerned—is completely safe and painless.  The technician applies some gel on the chest, which allows the ultrasound probe to have better contact with the skin.  The probe itself is like a speaker and microphone in one piece, transmitting and receiving the sound waves which are immediately analyzed and displayed on a monitor.

Of course, there is a great deal of skill involved in obtaining good images.  Because the heart is surrounded by ribs and lung tissue which interfere with the ultrasound images of the heart, one must find adequate “windows” to take a peak at the heart.

The procedure for a complete echocardiogram takes about 30 minutes or so.