By Dr. Nikita Fensham, MBChB (UCT) PGDip (IOPN)
Olympian triathlete Richard Murray recently announced his diagnosis of atrial fibrillation on his social media platforms. This subsequently sparked some criticism of his continuing to exercise, but also got a few followers concerned and interested to hear how he knew something was wrong.
It’s difficult to discuss the complexities around when you should and should not exercise with a heart condition, and that is not the purpose of this article. But what is more helpful is knowing when you might need to book for a check-up with your doc in the first place.
There are various estimates of the incidence of sudden cardiac arrest or death, but it is about 1 in 50,000 to 80,000 athletes per year. However, there is limited data to compare this to that in non-athletes. Further, this risk varies depending on sex, age, sport, and level of play.
Cardiovascular screening prior to sport participation is recommended by most sporting bodies who oversee athletes. This consists of a thorough history and physical examination, and possibly an electrocardiogram (ECG) as well, depending on the situation. From there, if any abnormalities are detected or there is cause for further concern, further investigations may be required to look at both the structure and electrical activity of the heart.
This work-up process would apply as well to recreational or competitive athletes who do not fall under sporting bodies. But since we are not automatically screened prior to deciding to take on our best 10k or first full distance triathlon, how do we know that our heart is “a-OK”?
The primary goal of screening is to identify those at risk of sudden cardiac arrest or death, as exercise is both a trigger and an unmasker of occult disease. But this screening also has a number of limitations. It relies on athlete honesty, knowledge of family history, presence of symptoms at the time of screening, the use of standard questionnaires by physicians, and the expertise of the physician interpreting the ECG. Certainly, an ECG that is interpreted by an experienced physician increases the chance of detecting an underlying abnormality, as 60% of disorders associated with arrest or death may have ECG aberrations.
As with any screening procedure, there is balance between the risk of over-diagnosis and benefit of preventing an adverse outcome. Notably, up to 44% of athletes who suffered sudden cardiac death had no structural heart abnormalities, and up to 80% of athletes had no symptoms at the time of screening (this is important as they may have had symptoms at a later date).
It all sounds very complicated, but a lot of the hard yards is up to the doc you consult as to which tests may or may not be appropriate. If a diagnosis is made, a shared-decision making approach has been increasingly favoured on both treatment options and return to sport and competition.
Given the complexities discussed above, it is important that you are seen by a sports physician and/or cardiologist who can interpret the ECG (and other investigations as appropriate) correctly, but also that you offer up as much information and history as you can.
With that said, the following circumstances are flags to see your doctor:
- You have been inactive and are now planning on starting exercise (you might benefit from a supervised program to start and your doc could refer you to the right service)
- You’re a smoker or take drugs
- Your heart has fluttered, skipped beats, or felt like it’s racing during or after exercise
- You have struggled to breathe during exercise out of proportion to the intensity
- You have experienced chest pain, discomfort, pressure, or tightness during exercise
- You have had a fit/seizure (and are not known with epilepsy)
- You have felt dizzy or light-headed during exercise
- You have passed out or nearly passed out during exercise
- You have a current medical condition or are taking medication that you have not previously discussed with your doc about with regards to sport
- You are diabetic, have high blood pressure or high cholesterol (or you do not know what your blood pressure, glucose, or cholesterol levels are)
- A family member has or had a heart condition
- A family member died suddenly and unexpectedly
- A family member has a pacemaker or an implanted defibrillator
Obviously, if you have any other concerns, it’s always worth checking in with the doc in case. There are certainly more benefits than risks of exercise, but sometimes athletes push themselves too far into the red zone too often, resulting in a J-shaped curve on how much exercise is beneficial for heart health.
Richard Murray is being a true role model in his approach to his current diagnosis, putting his health first. We should, too.
Medical disclaimer: This content is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. Always seek the guidance of your own doctor or other qualified health professional with any questions you may have regarding your health or a medical condition. Never disregard the advice of a medical professional, or delay in seeking it because of something you have read here.
Reference: Drezner JA, O'Connor FG, Harmon KG, Fields KB, Asplund CA, Asif IM, Price DE, Dimeff RJ, Bernhardt DT, Roberts WO. AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2017 Feb;51(3):153-167. doi: 10.1136/bjsports-2016-096781. Epub 2016 Sep 22. Erratum in: Br J Sports Med. 2018 Mar 6;: PMID: 27660369.