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  • Writer's pictureGary Moller

Sudden Cardiac Death among Older Athletes

The reason for revising this article stems from my recent participation in a multisport competition alongside my brothers. Tragically, a young man experienced a cardiac arrest right after completing the race. He was dead upon collapsing to the ground, injuring his face. However, prompt CPR was started and luckily, he'd collapsed within metres of the paramedic tent equipped with a defibrillator. The defibrillator was successfully used and he was revived, much to everyone's relief.


Despite the gravity of the incident, it seemed to me that, other than the cafuffle as it ran its course, things continued as per normal.


Now, here's the thing: Young people dropping dead, once extremely rare, and confined mostly to older people, is now commonplace. Dropping dead suddenly, is now across all age groups, including the very young. I worry that it is so common now that it is becoming normalised, just like people who come to live in Windy Wellington soon change their perceptions about what makes for a windy day!


Dr Guy Hatchard has written many articles that review the scientific literature about this alarming surge in sudden deaths. Here's the link to many of them: https://hatchardreport.com/?s=dying+suddenly


We mustn't allow premature deaths to be normalised, no matter the cause, but especially if the main cause is a medical procedure that's aggressively imposed upon a population. We must ask why sudden death is happening so often these days and take preventive action.


What follows is a guide about how to avoid suddenly dying while exercising. I wrote this some years ago. I've tidied it up and urge everyone to read it carefully and apply the ideas no matter their age.


May I wish you a strong and low pulse!


Gary


 


A practical guide about how to avoid suddenly dying while exercising


My father, Gordon, in his early 70's, died suddenly during his regular Sunday morning walk/run. He was about 20 metres into climbing a steep path when it happened. He was dead before he hit the ground. Looking back on it now, this was a good way for him to go, but it was untimely. He should have had at least another 20 years if only he had done some things differently.


Sudden cardiac death during exercise was extremely rare and it was difficult to identify common factors across all ages, but there are some commonalities with older athletes that point to ways we can reduce the risks a little, if not by a lot for everyone.


Although this article concentrates on older athletes, it's extremely relevant for young ones.


(When I was studying sports medicine at the Otago School of Medicine, one of my major topics was "The Risks of Sudden Death During Exercise")


 

An example of intense, brutal exercise at high altitude
Gary competing in the 2017 world champs at high altitude and in 34 degrees C heat; an extreme test of cardiovascular health and capacity.
 

The following guidelines apply to all intense sports and exercise, but especially to those that tend to start with a BANG! And sometimes stop that way as well.

 

What does medical research have to say about sudden cardiac death during exercise?

If you are into reading the technical stuff, please read this academic review, "Sudden Cardiac Death in Athletes" by Meagan M. Wasfy, M.D., Adolph M. Hutter, M.D., and Rory B. Weiner, M.D.:


Key Points that are taken from this review:

  1. Though exercise is, in general, health-promoting, it's associated with an increased risk of sudden cardiac death for a small number of individuals who harbour cardiac conditions.

  2. Sudden cardiac death is the most common medical cause of death in athletes, with an incidence of around 1 in 40,000 to 1 in 80,000 athletes per year, according to the most recent estimates.

  3. The risk and causes of sudden cardiac death vary based upon the athlete population. Male gender, black race, and basketball participation all place an athlete at higher risk. Sudden cardiac death in younger athletes (< 35 years) is commonly due to inherited cardiac conditions, while in older athletes (> 35 years) it's most often due to atherosclerotic coronary artery disease.

  4. There remains significant debate over the best strategy to prevent sudden cardiac death in athletes and the role of the electrocardiogram in pre-participation screening. The optimal pre-participation evaluation for a given group of athletes depends on the risk of the population and available expert resources.

The authors also said: "There was no associated plaque rupture on angiography in any participants with CAD, suggesting that the SCA was due to supply/demand mismatch".


Gary:

CAD = coronary artery disease. SCA = sudden cardiac arrest. SCD = sudden cardiac death


What we can take from this article are the following points:

  • SCD is rare and almost impossible to predict.

  • Pre-participation screening, other than for special groups, is of little benefit to the general population.

  • The most likely cause of SCD is insufficient blood supply to the heart to meet the dramatic increase in energy demands of the heart during intense exercise (a supply/demand mismatch). Hence the reason why the warm-up and starting a race advice I'm giving here is so very important for older athletes as a way of avoiding catastrophic supply/demand mismatch.

 

It's normal to prepare for these intense starts by doing a thorough warm-up, but this isn't always the case or possible. A paddler, cyclist, or runner may thoroughly warm up only to end up waiting, stationary on the start line in the cold and wet, starting the race as good as without any warm-up.


As we get older, several things happen deep within our bodies that increase the possibility of sudden death during exercise:


  • Plaque builds up inside our blood vessels. This is a like the scale that builds up in the water pipes of our houses. This is fatty and/or hard calcium. The makeup of the blood, protective nutrients, and the presence or absence of inflammation influence the rate at which this builds up.

  • Tissues, especially the arteries, harden due to scarring and calcification. This process, along with laying down of plaque, is happening in at least 80 percent of people and begins early in life. Hard, scarred, partially blocked blood vessels, as well as muscles that are more gristle than muscle due to chronic overwork and repeated injuries make it progressively harder to pump life-giving blood through the body.

  • Micro-blood vessels become damaged and blocked. Tell-tale signs of this process, atherosclerosis and arteriosclerosis, may be seen as the development of tiny spider veins, which are most obvious around the insides of the ankles. When your optometrist looks at the back of your eyes, micro blood vessel die-off is being examined.

  • Systemic inflammation increases with age. The modern, globalised diet can be described as "pro-inflammatory". Throw in toxins such as medications, arsenic, mercury, lead, herbicides, pesticides, illness, and disease - infected gums, for example - and excessive exercise - the inflammatory burden may be overwhelming.

  • Mineral and other nutrient imbalances and deficiencies get worse with age. Many minerals, principally calcium, magnesium, sodium, potassium, and iron, and the fat and the water-soluble vitamins, must all be plentiful and in balance for robust cardiovascular function.

  • Peak cardiovascular output declines by a factor of about 0.01 per year of life after the age of 28–30. This equates to about one heart beat less off your peak heart rate per year (this is where the 220 beats per minute - minus your age, comes from to estimate your age-adjusted maximum heart rate). So, the typical 50-year-old athlete has around 20 or more fewer heartbeats to play with as compared to a 30-year-old opponent. By 65 or 70 years of age, the loss of peak cardiovascular capacity is huge and it shows in performance.

  • The older athlete may be completely asymptomatic of any blood vessel blockages until the narrowing exceeds about 80 percent or more of a blood vessel's diameter. The only hint may be a faster than-expected deterioration of physical work output, and this is usually put down to "getting old".

As you read this, you might have realised that all of the above are independent of and not the inevitable consequences of ageing. They're preventable, manageable, and often reversible. Regardless of one's "old age", by the way.


The best measure of how well you are doing with this is your peak heart rate during exercise. If it is a little higher next year, despite you being a year older, then you are doing something right!


Reality checks:

  • The absence of symptoms doesn't necessarily mean the absence of disease.

  • You may feel nothing at all, but disease may be present, a bit like rust deep within your car's chassis. All is well until you run over a pothole at speed one day and the wheels fall off.

  • There's no such thing as a "minor" heart problem: All heart problems are serious!

  • Bear in mind that medical tests for assessing cardiovascular risk during exercise may be no better than 30 percent effective in picking up anything that may be amiss.

  • There's a fear among most doctors to acknowledge the common cause of heart problems these days (a medical procedure). Instead, they'll blame the patient, their genetics, their lifestyle, or their anxiety, while ignoring the elephant in the room. If the true cause isn't identified or acknowledged, then properly treated, a heart condition will be life-threatening.


 

Signs and symptoms of deteriorating cardiovascular health during exercise

 

For the sake of practicality, I'm restricting this section to what you, the athlete, can be assessing during exercise and rest, rather than including what may be measured in a medical or exercise physiology clinic.


These are most important for anyone who has a history of cardiovascular disease, including atrial fibrillation, angina, and heart attack. Bear in mind that first heart attacks are often silent and usually go undiagnosed, mistaken for a bout of indigestion or a chest muscle strain until the next and more catastrophic event hits.


Even if the cardiologist has just cleared you during your health check, which may have included an exercise stress test, please don't ignore any of the following:


  • Being unusually slow off the mark when the gun fires. Most older athletes know this one: the younger ones take off like crazy while the oldies gradually wind into the race, hoping later to overtake those inexperienced youngsters who went out too fast. If you are much slower than usual in getting underway, take care!

  • Cramping in the lower legs and/or more frequent problems with calf strains. This may be more of an issue at the beginning of exercise and may diminish as one warms into it. The other symptom to be aware of is calf cramps that wake you up during deep sleep.

  • Chest, arm, back, and groin pain during exercise. This may come on as the pace quickens or when going up a hill and relieved by slowing down. The cause may be cardiovascular and not just mechanical.

  • Migraine-like head-ache during exercise. This may be muscular but may also be due to sky-rocketing blood pressure or an aneurysm.

  • Feeling spacey or even loss of consciousness during exercise. The cause may be low blood sugar, but it could also be that the heart is failing and the blood supply to the brain is decreasing.

  • Irregular or racing pulse, or unusually slow pulse during exercise and/or while at rest.

Combine any of the above with a sense or feeling of distress and it is time to STOP! Lie down with your head and chest raised a little above your hips and prop the legs up a little as well. This position is the easiest on the heart by facilitating drainage of the legs and lungs. Get medical help. It is better to have some fuss made over you than to be dead. At the very least, slow right down, walk, finish early, rest up and book in for a thorough medical examination.
 

Hints that circulation to the legs may be declining

  • Foot and ankle pain or outright injuries that appear to come on from nothing, are very slow to heal and may even fail to heal fully.

  • Discoloration of the skin overlying the shins, wounds that are slow to heal, varicose veins, and spider veins. Your lower legs and feet are the points furthest away from your heart and lungs. If there is a significant loss of circulation, it'll often first be seen in the feet. Easy injuring, poor healing, cramps, and even deformed and fungal-infected toenails are indicators of deteriorating circulation to the legs.

  • Cold feet all the time.

  • Chillblains.

  • Fungus toenails.

  • Restless legs.

  • Leg cramps that are suffered during deep sleep.


 

Gary Moller Karapoti Classic race
Gary on his way to smashing the 60+ age-group record at Karapoti
 

Why do people suddenly die during intense exercise?


 

Think of sports like mountain biking, cyclocross, canoe and ski racing, and many running races: the gun goes and there may be a frantic dash to get the best position. In these races, a slow start can mean being caught in a massive traffic pile-up shortly into it, so everybody starts at a crazy pace!


Video below:

Look at the starts in the men's and women's races to get an idea of the intensity of the starts (Start viewing from the nine-minute mark for the start of the women's race, then the 53 minute mark for the men's race).



Squash used to be the headline sport for sudden death because it was popular with middle-aged males and usually began with little in the way of a warm up and typically finished suddenly when the time is up and the lights go out.


What do I think is going on.


The gun goes: everyone takes off like cats in fire: one drops dead shortly into the race. What happened? There could be several contributors:


  • Blood is like gravy: when it's cold it is sticky; when it's warm, it flows freely.

  • Blood vessels constrict when cold and they dilate when warm.

  • Spare haemoglobin for oxygen transport is liberated from the spleen several minutes into hard exercise. This release of extra blood into the circulation may be partly behind what is called "second wind".

  • If blood flow is compromised due to atherosclerosis. The heart must pump harder to get blood to the working muscles, and there can be a lengthy time lag in getting a good flow of blood back to the heart. So the heart ends up working harder than ever to pump while the refilling of the heart between beats may be poor. This is why older athletes often find fast starts difficult to handle.

  • There's a sudden and massive increase in lactate. The buildup of lactate from maximal effort peaks between 5–10 minutes after the maximal effort of the fast start. If levels of lactate become too high, this can become disabling. Muscles fail. The heart is a muscle, and it can fail as well. The sudden and massive increase in effort within the heart muscle itself may mean the localised buildup of lactate may be faster and greater than what may be measured in the blood.

  • Sudden and violent cardiovascular effort may displace blood vessel debris, such as blood clots and plaque. This debris may then lodge in a narrowed blood vessel, such as a coronary artery, triggering blood clotting and a resulting heart attack. Stress and sitting still for long periods, such as when flying or driving to an event may increase the risk of blood clots that may lead to deep vein thrombosis (DVT).

  • Imbalances and deficiencies in minerals (Mg, Ca, Na, and K) may lead to electrical disturbances during extreme exercise. Think of the role of these minerals in preventing and alleviating muscle cramps. The hardest-working muscle in your body is your heart, and what do you think will happen if it goes into a cramp?

  • Inflammation and damage to the heart from Spike Protein, introduced into the body via an mRNA "vaccine". I'll let Dr Hatchard explain it: https://hatchardreport.com/?s=myocarditis

A special note about caffeine and similar drugs

In recent years there have been a number of sudden deaths in New Zealand during exercise involving the use of pre-workout supplements and caffeinated drinks. Asthma medications, antihistamines, caffeinated soft drinks, tea, coffee, "No Doze", pre-workout supplements and some headache medications may or do contain various forms of "speed" that may have the heart racing wildly, especially when combined, such as a pre-workout supplement that is washed down with a Red Bull drink. Any product that contains caffeine or any other stimulant needs to be ingested with care and in modest amounts, if at all. When combined with intense exercise these drugs can induce heart arrhythmia. A clue that the drug may be a stimulant equivalent to what is commonly referred to as "speed", is if the name finishes with "ine" on the end, such as caffeine, ephedrine, adrenaline, methamphetamine, nicotine, and many antihistamines. If you are not sure of what you are taking, look it up on the internet or leave it out, unless it is absolutely essential medically. Talk to your doctor about this if you are uncertain about what to do.
 

Guidelines for competing in a competition without inadvertently killing yourself


 

  • Make sure you have plenty of recovery between training sessions and between competitions. Don't go into an intense training session or competition in a state of exhaustion. Many athletes get into such a state of chronic exhaustion through habitual over-training and too much racing that they may know nothing else. If your muscles are weak and tired, the chances are that your heart is tired as well. I've demonstrated this myself, by measuring the pulse and blood pressures of extremely fit athletes over the days immediately following exhausting exercise, such as running a marathon. Have 1–2 days of rest between hard training sessions and 2–4 days rest before a hard competition. Have 4–5 days of relative rest after a hard competition - ease back into training.

  • If travelling to a competition, take these measures to avoid blood clots (deep vein thrombosis). How to Prevent Deep Vein Thrombosis (DVT) in Athletes and Travelling Sports Teams

  • Warm up thoroughly. Start warming up about half an hour or longer before the gun is anticipated. Wear warm clothing and gradually build up to an intensity that briefly replicates what's anticipated during the competition. If the weather is cold, make the warm-up longer and wear more clothing. If the weather is warm, then the warm-up can be shorter. The fitter you are, the longer and more intense the warm-up can be. If you are unfit, be careful not to exhaust yourself during the warm-up. If you are preparing for a workout, and not a competition, your warm-up can simply be a graduated buildup of intensity during the workout and then winding down to "easy" over the final 10 minutes as a "cool-down".

  • Keep warm while waiting for the start and keep moving. You may notice that the pros in sports like mountain biking and cyclocross have stationary trainers that they remain on until the very moment that they are called to line up. While this may not be practical for you, keep warm and keep moving, even if that means jogging on the spot while waiting for the start. Wear extra clothing that you can toss to a supporter at the last moment. Some athletes participating in mass events, such as a marathon, will sometimes wear a rubbish bag or old clothing that can be discarded.

  • The warmer you are and the more you've been able to keep active up until the gun goes off, the faster and harder you can start. This may not always be easy since you may be corralled in with a hundred other eager athletes, all jostling for a good start position, so trying to keep moving may be impossible and attempts to do so may cost you a favourable start position. Do the best that you can and start slower if you have to.

  • Start slowly and gradually wind up the intensity. Apply smart tactics because nobody's heart appreciates a sudden and unexpected jolt into action. Let the young ones take off at a crazy pace, avoid the pile-ups as best you can then go as steady as possible later to reel in those who went out too fast.

  • Ease right off the pace if there is any hint of unusual distress and don't hesitate to stop. Live to fight another day. Intense competition hurts at the best of times. What we are talking about here are feelings of distress that are out of the ordinary, such as a dramatic loss of pace, feeling spaced-out, delirious, tunnel-vision, loss of balance, chest and arm pain. Remind yourself that this is only a game that you are participating in. Quit if you have to. Live to fight another day.

  • Race your own race - not other's. It's very easy to feel pressured to try to keep up with your main rivals. If they take off at the start like cats on fire, you must make the decision whether to go with them, or to hold back. Focus on yourself and not them; focus on how you feel and pace yourself wisely. Let them go, if you have to then gradually reel them back in later

  • Gradually cool down after the competition. While you may sprint and collapse over the finish line, don't just lie there, or stand around: Keep moving for another 20–30 minutes. Keep active to flush the lactate out of the muscles and give the heart a chance to gradually slow down, rather than subject it to an abrupt cessation. Rehydrate. Then go have a shower.

  • Consult your doctor. If you experience any unusual distress, STOP and please see your doctor right away! There's a time and a place to go and see your doctor, and this is one of them. Anything that might have something to do with your heart is best considered to be serious!

 

If you have a cold or influenza, or recently jabbed, should you be exercising?


Apply the "neck check":

  • If the infection is above the neck and confined to the nose and throat, then you may exercise. But please bear in mind that sore throats usually mean that your body needs a rest, so take a few days off. At the very least, keep the intensity toned right down.

  • If the infection includes below your neck, don't do anything other than the mildest of exercise. If your body is infected, aching, and feverish, you can assume that your heart is equally affected and distressed. Go home, go to bed. Rest!

  • If you have recently been jabbed with spike protein-generating mRNA, I'd say don't do any extreme exercise for the next eight months.


 

Final remarks


Sudden Cardiac Death during sporting events is rare and mostly unpredictable. It can strike anyone, ranging from those with Olympian fitness to the Weekend Warrior. Most of us know of someone who's died suddenly while exercising - I can think of several cases, including one former NZ running champion who, while recovering from the Flu, died suddenly at the end of an easy lunchtime run. He was in his early 50's. Nowadays, far from being exceedingly rare, these events have become the norm. Bear in mind, though, that the most hazardous place to be for a heart attack is in bed and first thing in the morning after getting up and moving about. Exercise is safe, and it can be made even safer by following these guidelines.


Exercise is good for you and good for your heart. Life is for living, and we never quite know when our number is up, so get out there and have a ball - make the most of the time you have but let's be sensible about the way we go about it.


 

Further reading:


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