Heat and Salt and A Fib

As stated previously I get pretty lightheaded when I get up from a sitting position after a hard workout, particularly in hot weather. Orthostatic hypotension. I don’t know why I get dehydrated so easily now, but I have learned that I need to eat something salty and drink a lot of water  after a workout, particularly a run or a bike ride which is longer than an hour or two, otherwise I get pretty dizzy when I first standup, and I’ve had a friend who is an nephrologist and another friend who is an internist both tell me to make sure I drink plenty of water after a workout and get some salt. Just one more fun aspect of being in persistent atrial fibrillation.

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Pre-Race Motel

This is the first time in my life I’ve ever actually been trying to get more salt. Most people spend their lives trying to avoid salt. I have started bringing potato chips for a post run snack to the trailhead for my long runs. Another great post run snack is some blue corn chips with some hummus with some Hoisin sauce.

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Pre-Race

Although it is neither here nor there, I’d like to state that I am a vegetarian (nearly vegan – if not for the occasional veggie pizza) as far as diet is concerned.

I also find that I am more sensitive to heat, which is obviously related. Last summer I would often start to feel pretty tired 17 miles into a 20 mile training run. In cool weather a 20 mile trail run is no problem. When I’m training for a 50K I basically try to do a 20 mile run every weekend.

Fortunately I live in Klamath Falls, on the East side of the Cascades of Oregon, where we have relatively cold Winters and generally cool Spring and Autumn. Summer, obviously, can be pretty hot – but nothing like Southern California, Arizona, Mexico, the South, etc.

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Resting During a Trail Run

I have also noticed over the past several years that I did quite poorly during marathons if the weather got hot. The concept of hot weather is a relative term – for me anything over 70°F (21°C) would be considered hot. My ideal running weather would be 35 to 55°F. Ten years ago I could do a 20 mile run when it was 90°F (32°C) without much problem. Those days are over.

I’d be interested in hearing from other people with atrial fibrillation with respect to this. Please comment.

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Ringo – Pooped Out After a Long Trail Run

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Persistent and Intermittent Atrial Fibrillation

There are different types of atrial fibrillation. They’re all the same arrhythmia, the main difference is duration. Some people have intermittent (or paroxysmal) atrial fibrillation. This means that the individual goes into atrial fibrillation for a short period of time – maybe a couple minutes, maybe twenty-four hours, but less than one week. Most of the descriptions of atrial fibrillation I have found on the web describe paroxysmal atrial fibrillation.

Atrial fibrillation that lasts for longer than seven days is called persistent atrial fibrillation, and atrial fibrillation that lasts for over one year is referred to as long-standing persistent atrial fibrillation or permanent atrial fibrillation.

Regrettably that is the type of atrial fibrillation that I have. I have just “celebrated” my one year anniversary of persistent atrial fibrillation. I miss sinus rhythm.

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The Best Mile Marker

People who are in sinus rhythm most of the time and go into atrial fibrillation only occasionally are fortunate because they get to be in sinus rhythm most of the time, which is basically the hot set up for any type of endurance sports. The disadvantage is that when these individuals to go into atrial fibrillation the effects are pretty devastating, and more often than not they find themselves on their hands and knees wondering what happened. The other bad news for people with intermittent atrial fibrillation is that it may very well progress into a persistent type atrial fibrillation, and of course there is a risk of having a stroke. So it is important to discuss this and formulate an appropriate treatment plan with your healthcare provider.

The disadvantage of being in persistent, but relatively asymptomatic, atrial fibrillation is that you have a performance penalty all the time; but the advantage is that you stabilize, at least I have, and are able to participate in your sport, albeit at a slower pace. It never gets much worse or much better.

Maybe there are some athletes out there who are in persistent atrial fibrillation who are unable to continue to participate in running, mountain biking, etc. if so I would encourage you to share your stories in the comments section.

All unable to discuss at this point in time is my own personal experience.

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Bizz Johnson Marathon – I think I’ve done this one five times

Intro – Atrial Fibrillation and Endurance Sports

It turns out atrial fibrillation is pretty common in middle-aged endurance athletes. About a year ago, when I first went into persistent atrial fibrillation I was surprised to find out how common it was in athletes, but also surprised to find out there weren’t a lot of resources on the web. I am writing this blog in order to provide information about atrial fibrillation in athletes from an athlete’s point of view only.

My purpose is not to give medical advice. I am a podiatrist employed at Klamath Orthopedics and Sports Medicine and my practice is limited to the treatment of the foot and ankle – not the heart. Cardiology is not in my scope of practice.

Also – before you ask – I don’t plan to give podiatry advice in this blog, either.

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I’m a 53-year-old distance runner and mountain biker who is in persistent atrial fibrillation. Persistent atrial fibrillation means that I do not go in and out of atrial fibrillation, like some athletes, I am always in atrial fibrillation and I am not expected to ever be out of atrial fibrillation. I am more or less asymptomatic, except for palpitations and, of course,  a slower pace, and do not take any specific treatment except for a blood thinner (Pradaxa).

I continue to enjoy marathoning, trail running, mountain biking, hiking, and any other outdoor activity for that matter. I am not sure how many marathons I have completed, but probably around fifteen. I have trained for two 50K runs, but was only able to run one of them. I was discouraged to participate in my first 50K by my electrophysiologist (more on that later). That was before he actually saw me as a patient.

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Peterson Ridge Rumble 20 and 40 Mile Trail Run – a great race that allows dogs. Here is my dog, Ringo, at the starting line.

My most recent event was the Peterson Ridge Rumble, a 20 mile trail run in Sisters, Oregon. Upcoming events include Lake of the Woods 15K, Siskiyou Outback 15K, and then the Bizz Johnson 50K in October.

I have done at least one marathon and one 50K while in atrial fibrillation, but I suspect that I have been in atrial fibrillation for at least one other previous marathon. It’s likely that I’ve been going in and out of atrial fibrillation for the past several years, and that explains a lot.

In 1994 I had open heart surgery to repair my mitral valve. At that time I was mountain biking six days per week and had severe mitral valve regurgitation and severe left atrial hypertrophy and I had a repair – no artificial valve or a pig valve – I have all the original equipment. Unfortunately the left atrial hypertrophy never resolved and as a result I eventually ended up developing arrhythmias, including a lot of PVCs and PACs, and have ultimately go on into persistent atrial fibrillation. PVCs and PACs, otherwise known as premature ventricular contractions and premature atrial contractions, are generally benign, but quite annoying arrhythmias that everybody experiences from time to time.

I am not happy (or proud) to be in atrial fibrillation, but this is what I have to deal with. I was told that in my specific case an ablation procedure would likely have less than 30% chance of being successful, and even if it were successful it would probably not be successful for more than five years.

I was never a fast runner, even in my youth and I’ve always been a big, slow runner (6′ 3”, just under 200 pounds), but now I’m ridiculously slow. But running still brings me the same joy that it always has and I plan to continue.

What Is Atrial Fibrillation?

Atrial fibrillation is the most common heart arrhythmia in athletes. The best explanation of atrial fibrillation, in my opinion, is from the Athlete’s Heart Blog:

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Atrial Fibrillation in Athletes (In a Nutshell)

One simple way of looking at it is to realize that when you are in atrial fibrillation the atria (plural of atrium –  the top two chambers of the heart which help fill the ventricles) are beating so fast it is as if they are not being at all, so in other words an individual who is in atrial fibrillation has had the misfortune of going from a four chamber heart to a two chamber heart. This reduces cardiac output to a certain extent, but does not necessarily exclude one from athletic activities. But it makes a runner who was previously a back of the pack runner into a runner who finishes right ahead of the people who are walking the race.

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Getting Ready to Run on the PCT

Pradaxa and CHADS2

The only specific treatment I take with respect to my atrial fibrillation is a blood thinner. I am on Pradaxa which for me, I believe, is a better choice than no anticoagulation, aspirin, or Coumadin (warfarin).

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Some of my Pradaxa

One of the worst things that can happen to a person in atrial fibrillation is that blood clots can form in the atria (plural of atrial), and can then release and become lodged in the brain. Since the left atrium is not really beating, and in my case it is quite enlarged, blood tends to pool here and this is perfect conditions for forming a blood clot. When a blood clot becomes lodged in the brain that is called a stroke or a cerebral vascular accident (CVA) and should be avoided at all costs. I actually met two different people, in one week, that had had strokes secondary to atrial fibrillation, and both of them were in their 50s. Both of them, regrettably, were lackadaisical about taking their anticoagulant at the time of their CVAs. Having a stroke, if you survive it, is an extreme life-changing event – definitely something to be avoided if possible.

Some people do not take any blood thinner at all. If your CHADS2 score is zero this is an option. My CHADS2 score is technically zero, but because of my severe left atrial hypertrophy my doctors think it is best that I am anticoagulated, and I fully agree.

What is meant by a CHADS2 score? Here is a link that explains, quite well the CHADS2 score:

CHADS2 on Wikipedia

Basically you get one point each for having congestive heart failure (C), being hypertensive (high blood pressure) (H), being seventy-five years of age or over (A), being diabetic (D), and you get two points if you have had a previous history of a stroke (S2). And it even spells CHADS2!

So, for example, if you are a ninety-year-old diabetic with high blood pressure and congestive heart failure, and you have already had a stroke, your CHADS2 score is maxed out at six points. Yes, you should definitely be on a blood thinner.

If you are a forty year old non-diabetic, non-hypertensive cyclocross racer who has demonstrated episodes of atrial fibrillation, but have no other risk factors, then aspirin, or no anti-coagulation at all, could possibly be an option.

If you have atrial fibrillation is important that you discuss this with your doctor and listen to what he or she has to say. I’m not giving medical advice here, I’m just explaining the system.

If your CHADS2 score is one aspirin or an anticoagulant such as coumadin may be an appropriate choice. But if your CHADS2 score is one or more you may want to be an anticoagulant such as Coumadin, Pradaxa, or Xarelto. Again, is important that you discuss this and agree with your doctor.

There are four choices regarding anticoagulation, and the choices are 1.) no anticoagulation 2.) aspirin, 3.) Coumadin,  and 4.) The newer, more expensive, but more convenient anticoagulants such as Pradaxa, Xarelto, and Eliquis.

Coumadin is relatively inexpensive, but interacts with a lot of different medications as well as a lot of different foods. I am a vegetarian and I eat a lot of green leafy vegetables which would make Coumadin a difficult choice for me. Also when I previously took Coumadin for six months after my open heart surgery I was having migraine headaches nearly every day. I rarely have a migraine since I discontinued Coumadin nearly 20 years ago. I don’t take any other medications, but if you do take other medications there’s a good chance that Coumadin may interact with them as well. Coumadin also requires frequent blood tests in order to make sure your anticoagulated at the proper level. Pradaxa and Xarelto do not require any blood tests. The disadvantage, and this is a big disadvantage, is that Coumadin is reversible if you do develop a serious bleeding episode whereas Pradaxa and Xarelto, for all practical purposes are not. It is possible that Pradaxa and Xarelto may be reversible with dialysis; but how likely is that????

Pradaxa is taken twice daily, and Coumadin and Xarelto are once daily. My doctor put me on Pradaxa after I was shown to have persistent atrial fibrillation. I have been taking it for over a year and really have had no problems. I’ve crashed my mountain bike just a couple of times and really haven’t noticed much difference as far as bleeding or bruising is concerned. But these were low-impact crashes and I realize there are some real dangers associated with anti-coagulation. It is important that you discuss this choice with your own health care provider.

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By the way – I am fully aware that there are a zillion commercials for suing the “bad drug” Pradaxa – but I am convinced, that for me, my diet, and lifestyle, Pradaxa is safer than Coumadin.

What Activities Are Safe While On Anticoagulants?

Trail running and mountain biking or both activities which have a certain risk for bleeding, that is to say there is a risk of falling. Being a person who is not naturally graceful I do tend to trip and fall more often than I would like while trail running on technical terrain. I do a little bit better as far as mountain biking is concerned, mostly because I have so many years of experience. Mountain biking falls are of greater risk than running falls because, obviously, they can be higher velocity and are more likely to involve a head injury. Head injuries are what you’re really trying to avoid, basically.

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Klamath Falls Mountain Biking Trails – Hot Lava

My cardiologists thought it would be a good idea if I discontinued mountain biking, and suggested that road biking would be all right. My opinion is that road biking has a much greater risk of a bleed because of the greater likelihood of crashing on pavement and/or being run over by a vehicle. All my best crashes have been on pavement.

But I understand why my cardiologist would feel this way. Every time I ever open up a mountain biking magazine, or see any depiction of a mountain biker in any type of media, the person is flying through the air catching what we call “hospital air.”

I don’t ride like that.

I have twenty-five years experience on the trails and am fairly cautious, especially since I started with anti-coagulation. Most of my crashes are low-impact and inconsequential. At this point in time there are a lot of trails I used to ride that I no longer ride because, frankly, they’re too dangerous. No photographer wants to take pictures of me riding my bike, simply because it isn’t very interesting, hence the “hospital air” photos in the mountain bike magazines.

bridge to nowhereArchery Trail – Bridge to Nowhere

My gestures of appeasement to the gods of subdural hematomas include a new (brightly colored) helmet and a more cautious approach to going through rocky areas along trail. I walk my bike through things I never used to walk through. That’s just the way it is now.

Also I have started to wear glasses while trail running – glasses for distance without the bifocal feature. I have decreased episodes of tripping and falling by over 90% because of this. I hadn’t even realized I needed glasses for trail running until I started using them.

When my cardiologist first told me I should discontinue mountain biking I went online and found a lot of forums about mountain bikers who are on Coumadin. It turns out quite a few mountain bikers take Coumadin, but not because of atrial fibrillation – primarily for deep vein thrombosis (DVT) prophylaxis. Evidently deep vein thrombosis is common in athletes as well. Anyway, there are quite a few mountain bikers out there who do get hospital air and are still in anticoagulants. That’s their choice.

This is not my video, but is an unedited eleven minute helmet cam video of a local trail – not too crazy

This is not what I do!

I’m really not sure what sports are safe and what sports are unsafe on anti-coagulation. I would imagine that sports that involve being flung through the air down to the ground and then being stomped on by a 2000 pound animal – rodeo, for example – should be avoided. And obviously sports that involved impact such as football, hockey, or boxing, karate and other fighting sports would be things to avoid. I haven’t actually been in a fight since 1981, but it still makes me sad to think that I am now pretty much unable to get in a fight. Jousting is definitely a no no. Maybe soccer, rugby, or even baseball are sports that should be avoided. Running, swimming, kayaking, backpacking are all probably safe. Rock climbing – maybe not so safe. Motorcycle jumping definitely unsafe. I’m not sure about skiing. I am definitely not going to sign up for any of these new obstacle races that are becoming so popular. I just don’t think it’s safe for me.

Atrial Fibrillation and Performance

I was under the impression that atrial fibrillation had not actually affected my pace that much, and that my slowing down was primarily a consequence of normal aging. I am fifty-three years old now and certainly can’t run at the same pace that I was able to when I was forty. One of my friends, who is approximately the same age as me, and also an endurance athlete, says that “every year is like a dog year now as far as performance is concerned.” In other words, for every year you get older you get seven years slower.

ringo racer

Every Year is Definitely a Dog Year for Ringo

I have always been a Clydesdale runner and at over 6’3″ in height I have spent the last ten years around 235 pounds. I decided when I went into persistent atrial fibrillation that it was finally time to lose the extra weight and have successfully kept my weight around 195 pounds for the past year primarily by means of a vegetarian/pretty much vegan diet. Conventional wisdom states that if you lose 10 pounds you get approximately 30 seconds per mile faster as far as your running pace is concerned. So I figured a 40 pound weight loss combined with persistent atrial fibrillation would mean more or less breaking even as far as pace is concerned.

I discovered that this is certainly not the case.

Last Fall I had a procedure called cardioversion, wherein the heart is zapped back into normal sinus rhythm, and I remained in sinus rhythm for thirty-three days before going back into persistent atrial fibrillation. My electrophysiologist thought it would be worthwhile to try cardioversion with a “one strike and you’re out” philosophy – in other words nobody really expected that I would stay in sinus rhythm, but it would be worth a try.

Video of a Man (not me) Being Cardioverted

It was during those thirty-three days that I realized that atrial fibrillation really does slow me down more than I had thought. Mountain bike rides that were taking me one hour and fifteen minutes in atrial fibrillation, where taking the fifty-five minutes in sinus rhythm – even though I did the exact same trails. I also found I was doing my training runs at a pace approximately 1 to 1 1/2 minutes per mile faster in sinus rhythm. This is a significant difference. When I finally went back into atrial fibrillation I had slowed down again.

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Running With A Fib Feels Like Running in a Foot of Snow

Being in sinus rhythm, by the way, was sort of uncomfortable for me. I am more or less asymptomatic when I am in atrial fibrillation as far as how I actually feel, but my sinus rhythm sucks. If I feel my pulse, while in atrial fibrillation, obviously, I can feel that it is irregular, but I don’t feel all that bad except that certain times – such as getting up to run across room to answer the phone, or right after I get done with a run. (More on that later.) But when I went into sinus rhythm I realized that my sinus rhythm really isn’t that great to begin with – I was having PVCs or PACs about every fifth or sixth beat, and these are noticeably uncomfortable.