Emergency Pack for Trail Running or Mountain Biking While on Anticoagulants (Coumadin, Xarelto, Pradaxa, Plavix)

Posted on May 30, 2014 by michaelpmccullough

This article is a work in progress and is only a description of my strategy for the time being. I hope to learn from readers of this blog about how to better plan for a trail debacle.

Heading out for a trail run on the Pacific Crest Trail

What kinds of things should a person like me, who is dealing with atrial fibrillation and is taking an anticoagulant (I take Pradaxa), carry on a long run in the wilderness? Or during a long mountain bike ride in remote areas?

When the high country in our local wildernesses is not covered with snow, I will generally do runs, nearly every weekend, of anywhere between six to twenty miles. I almost always run alone (except for my trail buddy – Ringo).

Dangerous and a bad idea? Possibly. But this is what I enjoy in life so I don’t plan on stopping any time soon.

The most important piece of equipment is a phone. People complain that everybody is always on their smartphone, and they should NOT be talking on their phones on mountain summits when everybody else is trying to get all Zen-like and self-actualized, and whatever – that’s a different discussion. You certainly don’t even need to have your phone on; but you absolutely should take it with you, and it should be fully charged. The days of getting hopelessly lost and spelling out SOS with rocks hoping a search plane will find you are fading into the past. A smartphone is a GPS and a direct link to help.

I always carry my iPhone in a baggie with my ID and a sheet of paper towel (which I use for unrelated toilet purposes).

Fully charged and protected from water

Even if there is poor cell phone coverage in your local high mountain or deep canyon wilderness, and a phone call isn’t always possible, I find that a text message can often still be sent. It might take a while but it eventually will be sent, especially if I am moving along a trail.

There is the standard emergency gear that most people take, often called the “ten essentials” which most people carry while in the wilderness. Of course there is truly no such thing as a standard ten essentials and the list of things you carry will vary depending on the season, your skill set, your location, and your past experience.

My generic survival gear

I got out my little survival kit that I typically carry in the wilderness, and of course not everything is pictured here, and I might not even have all of this stuff with me on any given trip. Naturally I will also have other things like food, gels, electrolytes, a jacket, and plenty of water.

What I found in my default wilderness pack is:

Two knives – a mini-leatherman tool and a standard knife. I will only actually carry one of these.

Two lights – a headlamp and a tiny LED flashlight (one is plenty).

Fire starter – a cigarette lighter, birthday candles, a tampon, and hand sanitizer (which I discovered has completely evaporated).

A space blanket, a compass.

Repair gear (Shoe laces, tenacious tape, dental floss)

Pain pills: Vicoprofen samples – okay they expired in 2000 but I’m guessing they are still good (at least for a placebo effect). Missing: Benadryl for allergies or yellow jacket stings, and I probably should have some of my Pradaxa in case I end up unexpectedly staying out overnight. Also missing: small roll of duct tape, safety pins, and my whistle!

Saint Christopher Medal

Oh, and there is a Saint Christopher medal. This one belonged to my grandfather. Well it probably won’t change anything, but it certainly couldn’t hurt. Feel free to substitute your own personal good luck charm.

But what about specific items for the runner on an anticoagulant? Is there anything else beyond the “ten essentials”?

Other stuff: Map with reading glasses (if needed) and some rope

Obviously having a major bleed while running alone in the wilderness would be a disaster. Death is certainly a possibility. How can a trail runner prepare to increase the odds of a good outcome?

I always make sure to let somebody know (usually my wife) where I’m going and I also send her a text (I text “OOTW” short for “out of the woods”) when I get back to my vehicle.

I also wear a Road ID. This way if somebody finds me they will know I am on an anticoagulant. Maybe this won’t help, but it certainly is worth wearing. At least they will be able to figure out why I bled out so quickly (I know – not funny).

My Road ID

Another item I always carry is a bandanna. This can be used for a number of purposes, such as making a field dressing; but I want to have it in case I need a tourniquet. Plus – I have an extra one because my trail dog always has one draped around his neck.

Bandanna

My bandanna came in handy a week ago when my wife Margo (not on an anticoagulant) crashed her mountain bike and punctured her left thigh with her brake lever. I used it to make a compressive dressing before we road our bikes back to where we could get a ride to the hospital.

One item I do not currently have but definitely need to obtain is a Quickclot field dressing. Evidently these things really work and are routinely used in combat situations. It is a topical coagulant (an anti-anti-coagulant?) which helps clot blood and also serves as a physical barrier to bleeding. I’ve been meaning to obtain one of these for a long time. They are available online via amazon.com, and I just ordered one.

Quickclot

Question: Will the Quickclot sponge even work on bleeding in an individual who is on a direct thrombin inhibitor like Pradaxa? Answer: I have no idea. I’ll let you know if I ever get a chance to find out.

In case of bleeding the most important first step is to apply direct pressure. As a surgeon I have a lot of experience with this. Usually sixty seconds of direct thumb pressure will stop or slow most bleeding, but of course if you take an anticoagulant it will take longer. Apply direct pressure as long as necessary. Elevate the wound if possible. Don’t try to clean out major wounds as this will restart bleeding – that can be done later at the hospital.

A tourniquet is a last resort, but the bandanna can be used as a compressive dressing if needed.

Please understand that an anticoagulant doesn’t completely stop clotting of blood, it just makes it take longer. Eventually bleeding will stop. Hopefully before all the blood leaves your body!

Ringo always has a spare bandanna for me

Bonus – How to stop a nosebleed:

I have been plagued by frequent nosebleeds since I was a child but, oddly enough, I haven’t had a single nosebleed since I started Pradaxa a couple of years ago. The best method I have found is to pinch the nose, fairly tightly, just above the nostrils, and lean forward. Don’t lie with your head back – that doesn’t work. Hold for a full sixty seconds. Repeat as necessary.

If you are, like me, a trail runner or mountain biker on an anticoagulant, I would love to hear from you. Please leave comments and suggestions in the comments area below.

Thanks.

Too Much Water? Not Enough Salt? Hyponatremia in Marathon Runners

Posted on February 21, 2014 by michaelpmccullough

Hyponatremia (low sodium, or “water intoxication”) is a risk for runners with atrial fibrillation. It is certainly a risk for me and I believe I have experienced it a number of times in the past. Personally, I am much bigger than most marathoners (6’3” 205 lbs), and because of that and the atrial fibrillation, much slower – so I’m out there twice as long and sweating twice as much. Plus – over the years it has been drilled into all of us to make sure we drink enough water.

Ironman athletes, ultrarunners, and bigger runners are all at increased risk because we are simply out there for much longer periods of time. Women athletes tend to be at higher risk for hyponatremia – it has been found that women hydrate more during a race.

Drinking enough water is a good idea – but it needs to be accompanied by increasing salt intake.

Normal levels of sodium are about 135-145 mEq/L. Symptoms are likely to begin at 130 or lower and if you get below 120 the condition may become fatal. While there are a number of medical causes for hyponatremia marathon runners fall into the category of consuming too much water and not enough sodium, and sweating out valuable sodium. Think of the white dried salt on your temple or on your hydration pack straps after a long run.

Symptoms include bloating, headache, swelling (check to see if your ring or wristwatch seems to be getting tight), nausea, vomiting and eventually weakness, restlessness, confusion, and well . . . it just gets worse from there. It is particularly problematic for runners because some of the symptoms (headache, nausea, cramps, and dizziness) are the same symptoms for dehydration so the impulse is to drink more water – which of course makes it worse.

There is currently an ongoing study at the Houston Marathon involving volunteers who are followed closely, weighed, fluid intake measured, lab studies obtained, etc. The study found that runners with lowered sodium levels drank more water, retained more water than normal volunteers, and they lost more total sodium and had saltier sweat.

Runners who were dehydrated but not hyponatremic had higher heart and respiratory rates, felt worse, and had lower blood pressure than hyponatremic runners. The hyponatremic runners felt better, but had more nausea and bloating.

What can be done?

Drinking less water is sometimes recommended but it is difficult to do when you are used to drinking a lot of water while running. I’ve tried drinking less water during a marathon and frankly I think it made things worse. Also some runners can become hyponatremic without over-doing the water consumption.

Weighing yourself frequently along the course and looking for weight gain (water retention) has been recommended – YEAH RIGHT! How is this going to happen?

Personally I try to drink water with sodium supplemented (NUUN, GU Brew), and try grabbing some little pretzels at aid stations (if available); but some research suggests this might not always be helpful.

“Watch out for feelings of confusion, nausea, fatigue, and particularly vomiting and swollen hands and feet. If you experience these, seek medical help.”

Fatigue? Really? Fatigue during a marathon – you don’t say? Isn’t that generally a part of the experience?

I don’t have a good answer. I know I’ve had problems with this – I’m clearly in the high risk category for hyponatremia. I also generally have particularly poor races if it is a warm day.

My interventions include

1.) Drinking enough water
2.) Electrolyte supplements in my water (NUUN, Gu Brew)
3.) Additional electrolyte supplementation (SaltStick caps, Endurolytes caps, little pretzels)
4.) Making sure I have a salty snack or meal after a race or long run
5.) Trying to dress so I’m a little cool rather than a little warm

I’d love to read your suggestions – please leave a comment if you have any experience with hyponatremia and suggestions as to how to avoid it.

Update (March 13, 2014):

I found this terrific article posted on Twitter by Dr. Larry Creswell. The key points are quoted below.

KEY POINTS

Most medical scientific organizations recommend low or moderate sodium diets to the general population in order to reduce the risk of high
blood pressure (hypertension).

Regular physical activity reduces the risk of hypertension.

Athletes lose sodium in sweat during exercise. The amount of sodium that is lost during endurance exercise depends on the sweating rate and
the concentration of sodium in the sweat. In turn, sodium loss during exercise depends on individual factors, such as genetics, fitness and heat
acclimatization, as well as the type, intensity and duration of exercise and the external environment.

Sodium ingestion by endurance athletes does not typically increase blood pressure, so low sodium diets are not recommended for individuals
who participate in long-term aerobic exercise.

Sodium ingestion during or following endurance exercise will help to stimulate thirst and drinking as well as stimulate fluid retention by the kidney.

No athletes are immune to hypertension, so athletes should monitor their blood pressure as they do their general health. This is particularly
important for older athletes, athletes with a genetic predisposition to hypertension, stroke or other cardiovascular disease.

Next Event – Vernonia Marathon Sunday, April 13, 2014

Posted on January 25, 2014 by michaelpmccullough

Training on the OC&E near Sprague River, Oregon

I’ve signed up for a Spring marathon – specifically the Vernonia Marathon. It is in Northern Oregon – North and West of Portland – a part of the state that I have never visited. I think this might be my 18th or 19th marathon but I’m not sure.

I just did my first true long run and I feel pretty good. I informally classify runs like this: two to six miles are shorter runs, like mid-week type runs. Medium long runs are nine to twelve miles. I’ll usually try to do a nine to twelve mile run every weekend even if I’m not training for anything. In fact, if I’m not training for anything at all sometimes that’s my only run of the week (with mountain biking or hiking on other days). I think of a true long run as being fourteen miles and up. There’s something about that distance that, for me, seems pretty serious. Anything over thirteen requires more fortitude.

I didn’t just start training for an April marathon this weekend – I’ve been training for weeks – but my weekend long runs have only been eleven to twelve miles.

As far as my atrial fibrillation is concerned nothing has changed – I remain in atrial fibrillation all the time, my running has slowed, and I need to make sure I drink enough water and eat something salty afterwards. After the fourteen miler I went through the drive through at Burger King and bought each of the dogs a cheap burger from the value menu (the dogs aren’t vegan), and just an order of fries (with salt) for me. This way I avoid the dizziness I sometimes get from standing up after a long run.

Sophie Tired After a Long Run

The Vernonia Marathon course is on a paved bike trail. This is the first Rails to Trails project in Oregon – the OC&E Woods Line State Trail being the second. I chose it because I like to train on the OC&E and have completed the Bizz Johnson Marathon (on an un-paved rail trail) seven times.

Sophie on Paved Portion of the OC&E Trail

I dislike running on pavement so hopefully there will be a dirt trail off to the side of the paved part. If not – well, a paved trail seems a lot softer because it is simply pavement on top of gravel as opposed to pavement on top of concrete (which is what our local streets are.)

I expect the Vernonia Marathon should be a small, informal, fun race and I won’t know anybody there except for my friend Claude who is also going to run it.

Winter Training

My race strategy is to start out slow and then take it easy. The course profile looks hilly – but how steep can a rail trail be? Trains can’t go up more than a one or two percent grade, right? I think the hills will be gradual – like the Bizz Johnson course.

Funny – I always enjoy the training much more than the actual races.

If anybody has any experience with this event please comment below. See you there.

Atrial Fibrillation News Update

Posted on January 19, 2014 by michaelpmccullough

Here are a few internet news stories related to atrial fibrillation. In the future I’ll try to update more frequently so I don’t end up with four topics in one blog entry.

AFib Doubles Risk of Heart Attack in Women and African Americans

Overall, the increase in risk of heart attack was about 70% in AF patients, even after accounting for other cardiovascular disease risk factors, such as hypertension, high cholesterol, body mass index, and history of stroke and vascular disease. However, when the researchers looked at subgroups, they found that increased risk of heart attack was more than doubled in women and African Americans with AF—but less than 50% for men and whites with AF.

I’m not sure what to say about this – hopefully runners with atrial fibrillation (who hopefully also have other heart healthy lifestyle choices – like a healthy diet, not smoking, reasonable body weight) will do better than the general population. One bit of good news – the blood thinners a fib patients take to prevent stroke also seem to help prevent heart attacks.

Drug Interactions with Novel Oral Anticoagulants

“Novel” anticoagulants refers to the newer prescription anticoagulants that are used as an alternative to Coumadin (warfarin). Specifically: Pradaxa (which is the one I currently take), Xarelto, and Eliquis.

I can tell you that as a clinician there are not many things more frustrating than prescribing medications for people who are on Coumadin – it seems like it interacts with everything! One of the great things about the newer anticoagulants is that they have less drug interactions – but they still do have potential drug interactions.

Please click on the link to see tables for drug interactions involving Pradaxa (Dabigatran), Xarelto (Rivaroxaban), and Eliquis (Apixaban).

Obviously all of the novel anticoagulants can interact with any other drug that is *ALSO* an anticoagulant – like Plavix or aspirin. Keep in mind that this includes NSAIDs like Alleve (naproxen), Motrin (ibuprofen), etc.

Personally, I completely avoid taking ibuprofen and naproxen – but every once in a while (like after a brutal long run) I will take a Celebrex. Tylenol (Acetaminophen) is fine – no interactions with the anticoagulants (although it has its own issues).

By the way – if you read the article and see a possible drug interaction please don’t stop taking any of your meds – but contact your own doctor immediately for advice.

Warfarin May Up Stroke Risk in Those With Irregular Heartbeat: Study

A recent study has shown that Coumadin (warfarin) actually increases the risk of stroke for people in atrial fibrillation during the FIRST THIRTY DAYS of warfarin therapy. That’s just the first thirty days – the idea is to prevent having a stroke, and that’s what taking Coumadin does.

This finding does not suggest that anything will change – doctors are still going to put people on warfarin to prevent stroke. They just have to get through the first thirty days!

If you are on warfarin and you read this article – please do not stop taking your medication.

FDA Panel Gives Support To Novel Stroke Prevention Device From Boston Scientific

Finally – the FDA has not yet approved the Watchman left atrial appendage closure device by Boston Scientific – but it has given a “vote of confidence.” It appears that this gadget, which is implanted in the left atrium to prevent the formation of the clots that cause strokes, may be approved by the FDA for the US market late this year. The majority of the panel agreed that the Watchman was equivalent to standard treatment with warfarin, but it hasn’t been compared to the new novel anticoagulants (see above).

Atrial Fibrillation Stroke Calculator

Posted on January 9, 2014 by michaelpmccullough

Atrial Fibrillation Stroke Calculator

I saw this link today on Facebook and thought I would share it – it is an AF Stroke Risk Calculator, and was posted by the Atrial Fibrillation Association – a great resource for people with atrial fibrillation. As you probably know one of the greatest risks of being afflicted with atrial fibrillation is that it can lead to you having a stroke. Blood clots can form in the malfunctioning atrium, break loose, travel to the brain and – BOOM!!!! – you’ve had a stroke. Prevention is the best approach.

This calculator is basically a clever automated version of the CHADS2 score. I was delighted to find my risk is 0%.

But if course my risk is definitely higher than zero percent – even if my CHADS2 score is zero.

My heart is abnormal in more ways than the atrial fibrillation. I have hypertrophy of my left ventricle (from running – not a risk factor) but I also have “severe hypertrophy” of my left atrium (the top chamber of the heart) which my cardiologist assures me is a risk factor for stroke and although my CHADS2 remains zero I am on an anticoagulant (Pradaxa).

My question has been: Why not include left atrial hypertrophy in the CHADS2 calculation?

Answer: I dunno.

Lillian and Lolawanda ready for another trail run

My other question has been: What else can I do to reduce my risk of a stroke?

I understand my risk is NOT zero, regardless of what this calculator says.

Obviously one thing I know I can do is to remember to take my Pradaxa twice daily. Believe me, for somebody who is only taking one medication it isn’t as easy to remember as you might think. I have considered switching to Xarelto simply because of the once a day dosing.

My Pradaxa

But other than that what else can I do? One more thing (I think) – stay well hydrated.

As a large, slow, long distance runner (who is often on the trail for several hours at a time) I sweat more than smaller runners, and I have to be very careful not to become dehydrated. I spoke with a friend of mine who is an Internists/hospitalist and he agreed – don’t become dehydrated. Being dehydrated can literally thicken the blood and increase the chance on a clot, and therefore increase the chance of a stroke.

Be Careful Out There!

How much water should a person drink? I have no specific prescription but what I do is try to drink enough so that my urine is relatively clear once per day. Also there is such a thing as too much water and big, middle-aged distance runners are at relatively high risk of hyponatremia (too much water – not enough sodium) so be careful out there!

We talked about other risk factors are there? Risk factors for blood clots in the legs include being inactive, obesity, and smoking – probably less likely for the readers of this blog.

Sedentary after a LONG RUN

What about alcohol? Does that increase the risk? He said probably not and in moderation might even decrease the risk – but remember – alcohol clearly increases your risk of atrial fibrillation – and if you drink enough alcohol you will become dehydrated – so there you go!

By the way – don’t expect this this risk calculator or this blog to advise you as to whether or not you should take your aspirin, your warfarin (Coumadin), your Xarelto, or your Pradaxa. It is important that you make this decision with your doctor.

Run, Smile, Drink Water and Don’t Die – A Guest Post by JoAnna Brogdon

Posted on January 5, 2014 by michaelpmccullough

Once upon a time there was a girl that loved to run just for the fun of it. She woke up early one morning on a cold and rainy March morning, excited to run the Rock Creek River Gorge Trail Run at Prentice-Cooper State Forest, just outside Chattanooga, Tennessee. She had run this race before and was wowed by the gorgeous gorge views and challenging single track trails.

She signed up for the 10.2 mile run but wasn’t feeling exactly right that morning. She couldn’t put her finger on it. She was just a little off but that wasn’t going to stop her! She bounced out of bed and decided to do the 6.5 mile option instead of the 10.2—a decision that turned out to be one of the best she ever made.

The start was a little fast. Everyone was ready to get moving on the chilly and very wet morning. Soon the 158 runners headed into the woods and formed a single line, slowing the pace which was a good thing. The trails were incredibly slippery with tons of thick mud after much rain that winter. One runner took a face plant when crossing the creek and came up with a big gash on his forehead and blood dripping down his face.

“Are you OK said the girl?”

“Yes, I am just happy to be out here,” he responded.

“Me, too!” she replied. There were smiles on everyone’s faces as they headed up steep hills and carefully focused on the each step.

At the half way mark, she was feeling OK but a little more tired than usual. No problem she said to herself, just having an off day. It was time to focus on other things, talk to people, make some jokes and carry on. She found a guy wearing a shirt that said, “Idiot Runner’s Club – Run, Smile, Drink Water and Don’t Die.” This sounds like my kind of runner thought the girl! They chatted and laughed about how slow they were going but how happy they were to be there instead of sitting on a couch or still sleeping in bed. The mud was so thick that their shoes nearly got sucked off but happily they went up yet another hill.

Even though she wasn’t moving very quickly, her heart was starting to race quite fast. She slowed down and was walking more than running. She put her hands in the air a few times feeling like it was getting a little hard to breathe. Just focus on the gorgeous trails and it will be over soon, she told herself.

There is that Idiot Runner again. He caught up and they were passing each other back and forth. It was time for more chatting and laughter. Only a few more hills and it will be time to relax and enjoy the day. One final push, climbing up through the narrow Indian Rockhouse and the race is almost over.

It is only 6.5 miles, she thought why does this feel so hard? She had run 50Ks and didn’t feel this bad. There goes a female racer. She will have to see if she can catch her but just felt so tired and ready to stop. Then she heard the crowd and knew that the end was near. She pushed as hard as she could one final time to make it to the finish line—she did it! And then she decided to sit down for a minute, she really didn’t feel so good … and then there was darkness …

…what is that noise?

She was waking up and heard a loud noise – it was her heart pounding at an incredible rate and a bright light in the distance. Someone was saying something to her, if she could only get to the light. She woke and found herself inside the medic tent with two physicians by her side. Her legs were cramping with the worst pain she had ever felt. Where was she? What had just happened? What was her name? Which hospital did she want to go to? So many questions…

She was being placed in an ambulance and sent to the local hospital. She was in rapid rate Atrial Fibrillation and needed a Cardizem drip to get her rate down. They admitted her to the hospital and the nurse came by to explain what A Fib meant. She drew a nice picture for the girl.

She learned that A fib occurs when one or both of the upper chambers of the heart – called the atria – don’t beat the way they should. This can cause blood to pool in the left atrium, where a blood clot can form. If that clot breaks away, it can travel to the brain, where it can cause a type of stroke called an ischemic stroke.

Two and half days in the hospital she waited for the meds to convert her heart back to normal sinus rhythm. They placed a band on her wrist that said “fall risk” – they had no idea.

The doctor decided the only way to get her heart back to normal rhythm was to cardioconvert using an electric shock. She was wheeled down to the operating area and what a surprise– she saw the two doctors that were at the race. One was a cardiologist and the other was an anesthesiologist for cardiology. They were chatting and laughing and encouraging her that it was all going to be OK. Her cardiologist was running late and it delayed the procedure. He was known for this as he always took time with his patients. Right as the doctor arrived; the nurse looked at the monitor and said wait—she converted on her own! We don’t need to shock her heart. The girl was happy and believed that it was actually going to be OK— maybe not happily ever after but OK. She smiled as she remembered the new friend she had just met on the trail…

“Run, Smile, Drink Water and Don’t Die.” Now those were words to live by.

The End.

JoAnna Brogdon, forty-three years old, went into a fib several times since the race and was hospitalized twice. She has no underlying chronic conditions and the doctors are unable to tell her why she has had a fib. She believes the worst part of the condition was the emotional stress and not being able to exercise as she had in the past. She underwent a cardiac ablation recently and her heart has been beating normally since. She is hopeful that she has put a fib behind her at least for now and looks forward to running, traveling and feeling normal again. JoAnna wants to support those that struggle with a fib and may be contacted at joannabrogdon@hotmail.com.

Rejoice – Not All Runners in Atrial Fibrillation Are Slow

Posted on December 27, 2013 by michaelpmccullough

Moore Mountain 1/2 Marathon

The thing I enjoy most about the afibrunner blog is comments from other athletes who are dealing with atrial fibrillation. A recent comment from a runner (we’ll call him “Lon”) really caught my attention – here is a runner who, while in atrial fibrillation, was able to race at six minute mile pace (or better).

Here are some excerpts from his comments:

Way to Go!!!
Since 1983 I’ve run/jogged 59 full marathons and have suffered with A-fib on and off for the last 12 years. I’ve finished the Boston (2001 in 3:23) and NY City (2005 in 4:15) marathons while in constant A-fib while carefully monitoring my heart rate. My cardiologists encouraged me to run marathons and also triathlons. One cardiologist told me that my heart is so strong that it laughs at A-fib and that I have the heart of an olympic cyclist. For the first 6 months of this year my heart was in constant A-fib that no drugs or multiple cardioversions could put it back into normal sinus rhythm. On July 9, 2013 I had the “Wolf Mini-Maze” (at the International A-fib Center of Excellence in Indianapolis) operation done on my heart. It was a great success and my heart has been in constant normal rhythm ever since (nearly 6 months now and I’m not taking any medications). In the Mini-Maze they removed my Left Atrial Appendage (LAA) so that if my heart ever goes back into constant A-fib I will NOT meed anticoagulant therapy. As you likely know life threatening blood clots tend to form in the LAA when your heart is in constant A-fib. The risk of stroke over the life time of an A-fib patient is huge. 3 out of 5 A-fib patients will suffer a stroke in their life even while taking anticoagulation meds like coumadin. That is a statistic that your doctor will not likely tell you about. Coumadin is over rated and is simply not very effective for some people which should be a terrifying realization to anyone dealing with A-fib. Anyway, as much as I love marathons, I’m laying off the long distance jogging for a while and am just jogging 10K’s (one per moth and 3 sprint triathlons this Summer) as well as several other physical activities.
Good health to you!
Lon

I have lamented that atrial fibrillation has made me slow, while openly admitting that I started out slow – I’ve only ran, as far as I know, one six minute mile in my entire life – and that was thirty years ago.

Finish Line – Eugene Marathon

My understanding about atrial fibrillation is that the atria no longer preload the ventricles, and most people have a decrease of about 20% of their cardiac output. While sedentary people might not even notice this athletes certainly would. I do!

But I have heard that in some patients, certain athletes, there is little change in cardiac output and atrial fibrillation will not affect performance much. Lon seems like one of these fortunate people. Lon’s point about the increased risk of stroke (even if you take your Coumadin, Pradaxa, or Xarelto) is well taken – and I’m guessing that that is why he continued to pursue an effective treatment for his atrial fibrillation.

Finish Line – Haulin’ Aspen Marathon

But after all those marathons Lon states he is no longer running endurance events – he goes on to elaborate:

Here’s a little more. I tried not to make a long story short above. I left out mentioning that I had a radio-frequency catheter ablation in June 2010 in Seattle that worked great in keeping my heart in normal rhythm until December 2012 when suddenly for no apparent reason went into persistent A-fib. (During that 2 1/2 year period I finished 9 full marathons and 8 sprint triathlons) My heart stayed in persistent A-fib even after 4 cardioversions and large doses of amiodarone. My cardiologists in Seattle told me that I should accept my persistent A-fib and they offered to ablate my hearts pace makers (AV and SA nodes) and give me an electronic pacemaker so that my heart rate can be controlled. That told me that I needed a second opinion so I started communications with Dr. Randall Wolf in Indianapolis about his Mini-Maze procedure. After consultations with an E.D. doctor (and a championship Iron Man triathlete) who had the Mini-maze operation and was very happy with the results, I decided to get the Wolf Mini-Maze and of course I informed my Seattle cardiologists of my intentions and they said to go for it. Absolutely the main reason that I went for the Wolf Mini-Maze is that it removes the left atrial appendage which brings my risk of stroke down to that of a healthy person with a normal healthy heart while not taking any anticoagulation drugs. The fact that I now enjoy a normal heart beat is just a huge plus factor.

From 1983 until December 2012 I completed 61 full marathons a most of which ran with all out efforts (I’ve averaged sub-6 minute pace all the way). I’m now finding out that long distance running is simply not good for the heart and most likely caused my A-fib problem.

Google Dr. John Mandrola’s 18 minute video called “Cycling Wed: I told you so…”. It is very illuminating and a must see for all endurance athletes. Please check that out.
Cordially,
Lon

I don’t know much about the Wolf Mini-Maze procedure and don’t necessarily advocate it for everybody, but clearly it worked in Lon’s specific situation. Here is some information regarding the Wolf Mini-Maze.

Finish Line – Lake of the Woods 15K

No need to Google the video by Dr O’Keefe (posted on Dr Mandrola’s blog) I have the link right HERE.

Here’s the video:

If you don’t feel like watching the eighteen minute video I will summarize it for you – Exercise is good for you but in moderation. Too much or too intense exercise causes chronic inflammation of the heart and can ultimately harm the heart (atrial fibrillation, among other risks).

But if you are an endurance athlete dealing with atrial fibrillation you already know this – surely you have had a dozen or so friends and relatives, possibly sedentary and/or obese, kindly forward you information about the study he refers to – as if to justify their seemingly wise choice to avoid marathons and triathlons and replace it by watching other people play sports on television. Yes, this study was in all the newspapers and magazines last year.

Finish Line – Avenue of the Giants Marathon

Please understand, and I paraphrase here, that Dr O’Keefe states that exercise is good for your heart, and being obese and sedentary is bad for your heart – but that overdoing it is a problem. He didn’t say people should avoid exercising.

My choice – I understand the concept of the “law of diminishing returns” as well as the next guy; but for me, well, I enjoy long, slow trail runs and mountain bike rides more than just about anything else I can think of – so I chose to continue.

Finish Line – Bizz Johnson 50K (I completed the 50K in atrial fibrillation)

Race Report – Bizz Johnson Trail Marathon, October 13, 2013

Posted on October 16, 2013 by michaelpmccullough

Runners at the starting line 2013

This year, October 13, 2013, was my seventh time running the Bizz Johnson Trail Marathon. My first time was in 2007 and I have ran the event every year since then. Last year I ran the 50K (31 miles), but it is pretty much the same course, just 5 miles longer.

Has anybody reading this blog knows I have been in persistent atrial fibrillation for the last two years. For the 50K last year, and the marathon this year, I was in known atrial fibrillation. I am pretty sure that I went into atrial fibrillation about two thirds of the way through the 2011 marathon. At least (in retrospect) it felt that way, but that was before I knew I was afflicted with this dysrhythmia.

It took a long time to get to the finish line this year

The course of the Bizz Johnson Trail Marathon is well known to me and I enjoy it a great deal. The Bizz Johnson Trail is a rails to trails project, and is about 24 ½ miles long. For that reason the race begins with an out and back on a Forest Service fire road in order to make the marathon and official 26.2 mile run. Once the runners get on the actual rail trail the course is a gentle uphill until about the 6 mile marker at which point there is a 20 mile downhill section. This might sound like it’s easy, but remember, it’s a run not a bike ride. This is the only race where afterward I typically have a lot of quadriceps and heel pain from all the downhill.

Except for the portion where the trail crosses the Susan River Canyon the grade is very gradual. Trains evidently are unable to go up or down anything that is too steep, and the average grade is below 1%, and at its steepest probably about 2%. This is an estimate, I’m really not sure of the exact grade. One thing I can say, though, is that the steepest downhill is the last 6 miles down the Susan River Canyon. This is also where the course is the most scenic (including two tunnels) and often this section is quite warm.

This year the deciduous trees were changing and it was quite beautiful.

Along the course (No deciduous trees here – sorry)

Some people worry about the elevation at Bizz Johnson, but to me that isn’t even a factor. I live and train at the exact same elevation as the Bizz Johnson Trail. As a matter of fact I do almost all my training on mountain biking and hiking trails which are much steeper and more technical than the Bizz Johnson Trail.

I have to admit I had a bad time this year. I don’t think it had anything to do with the atrial fibrillation per se, I think I worked myself into a bad attitude, or bad mental state this year – ruminating over certain past events on the two and a half hour drive to Susanville the day before the race. Also I had trained for the 50K, but I really didn’t feel up to it and the day before the race I switched to the regular marathon. This probably was a good move, but I felt somehow depressed over that choice.

I’m not sure how many marathons I have ran, but it’s somewhere between seventeen and twenty races. There comes a time in every marathon where I start to feel poorly, but usually I don’t start to feel that way until somewhere around mile twenty-two or twenty-three. For some reason at this year’s Bizz Johnson I started to feel that way about mile six. “It’s going to be a long day,” I told myself.

Ultimately I completed it, I suffered like an animal, but I lived to fight another day. It’s interesting that I finished it at almost the same time that I finished the 50K last year, that is taking into consideration that the 50K starts an hour before the regular marathon. My recollection of the 50K last year is that I felt much better, surprisingly, throughout the entire race than I have during any previous marathons. Maybe I should stick with 50Ks.

My friend Stephen, who ran the race this year as well, said he suffered like an animal as well, and that “it seemed like every mile hurt.” But then again he finished several hours ahead of me, came in seventh place overall, and won his age group. It was probably worth it.

Sometimes I wonder – am I good at marathons? Maybe. Maybe not. I’m certainly not fast. Seems like I did a good job, the night before, sitting in a motel room watching sitcoms. Maybe I’m better at something like that. Well, I guess I’ll have to keep trying marathons until I get one right.

Finishing the 50K last year

Being a veteran trail runner who has to be self-reliant, except during a race, I carry my own water. I use an Ultimate Design WASP hydration vest, with NUUN tablets added for electrolytes. I refill it at the water stops if necessary. This year, for some reason, I figured I should probably drink some of the electrolyte drink that they offered at the water stops in addition to my own concoction. I should have known better. It was a pink drink that is evidently marketed by the Power Bar company. I have never tasted a urinal cookie before, but I imagine that this pink sports drink is pretty close. Every time I drank a Dixie cup of it at a water stop I had to walk a little bit and try to hold it down. In other words I was having a lot of nausea. Being nauseous will not prevent me from drinking because I figure I can always drink more water if I vomit, but it sure does keep me from eating, so I was a little deficient as far as carbo gels were concerned. I think I only had two all day (and had planned on five).

During last Sunday’s race I decided that the mile between mile marker twenty-three and mile marker twenty-four is definitely the cruelest mile. Suffering is maximized, and you’re close but not really close enough to the finish. If I tell myself, “it’s only three more miles!” I then start to think that three miles sounds like a terribly long distance.

I enjoy listening to music on my iPod shuffle while I run and when I arrived at the last quarter mile of the race a terrific song came on my iPod. It was Oh Comely by Neutral Milk Hotel. Unfortunately I was feeling remarkably emotionally labile at that point in time that I knew that if I listened to the song I would start crying. I already knew I was suffering and wasn’t going to appear well coming across the finish line, but I really didn’t want to finish crying like a little kid – so I fast forwarded it. I clicked until I found a song that was a little bit more emotionally bland.

When the finish line mercifully appeared I was glad to be done. I strolled over to the feed section and as usual there were a lot of great things to eat, but I was feeling so nauseous – there was not one thing there that I could’ve eaten. Claude, who also ran the race that day, was waiting for me and we took the shuttle back to the parking area. I had some food in my truck for post race meal, but as soon as I walked over there I became quite sick and expelled a large quantity of pink water. It must have just sat there in my stomach – there was a lot of it! I felt much better, changed into my dry clothes, and ate my post race meal. I started to wonder – emotionally labile, tearful, and nauseous – was I pregnant? (Ha ha)

The Fear of Going Too Hard – Atrial Fibrillation Running

Posted on October 10, 2013 by michaelpmccullough

One big difference between running in persistent atrial fibrillation and normal sinus rhythm is that, for me anyway, there is a lot of apprehension about over-doing it. The days of charging up a hill may be behind me at this point, and I haven’t done anything resembling a speed work-out in well over a year.

Prior to atrial fibrillation I used to do interval work-outs once in a while. For certain marathons where I had a specific personal time goal I would do a work-out known as “Yasso 800s.” Although some expert dispute that this is actually the most effective speed work-out for marathon training, nobody would dispute that this is a difficult work-out. I would do them on Wednesday nights at a local college track and I always felt they were my most difficult work-out of the week – probably more challenging than my languorous week-end long runs. Certainly this was the work-out where most feared injury.

To be honest I don’t miss Yasso 800s. I never have been a fast runner and never enjoyed short fast races like 5Ks.

But even during LSD (long slow distance) work-outs there usually comes a point where I will feel that the run is becoming difficult and I have to push through that. People often say “push through the pain,” but it isn’t really “pain” per se; but whatever it is it now makes me nervous!

But now that I am in persistent atrial fibrillation I think twice about pushing beyond any thresholds, however they are described. I have a fear in the back of my mind that I am going to make the atrial fibrillation worse, or pass out, or die, or . . . well who knows? This is all new territory for me.

I think this is why I “bonked out” of the second and third (out of seven planned) twenty mile runs I did during my build-up to this Sunday’s Bizz Johnson 50K. I just wasn’t willing to risk it. But if I’m unwilling to risk it it is obvious that I will only get slower and slower each year.

RINGO SAYS RELAX

I’d love to hear from other endurance athletes about this topic whether you are in a fib or not, and whether you are risk averse or not. Please feel free to leave a comment.

Pacific Crest Trail on Atrial Fibrillation?

Posted on August 15, 2013 by michaelpmccullough

I live near the Pacific Crest Trail. The famous, fabled, fabulous PCT. Just about twenty-five miles away. You can look out our back window and stare lovingly at the mountains where it courses through the Sky Lakes Wilderness.

Heading out to run on the PCT

Although I come off in this blog as a marathoner, or an ultrarunner, what I really enjoy more than anything is trail running (and mountain biking – but mountain biking is forbidden on the PCT so forget about that). I simply love trail running and hiking, especially in the local Sky Lakes Wilderness and Mountain Lakes Wilderness; and the best part of being at my level of fitness and health is being able spend a weekend day doing a ten, fifteen, or even a twenty mile trail run. Although it is a slog now because of the atrial fibrillation I still love it – I love the movement through the wilderness and I love the trail itself.

Usually the only one who goes with me is my little trail dog – Ringo.

Ringo on the PCT at Brown Mountain

At this time of year – late Summer – all the thru-hikers, or I should say the small percentage that have made it this far, are coming through Southern Oregon. Most thru-hikers are traveling from South to North; they start at the Mexican border and hike through California, Oregon, and Washington with the goal of reaching the Canadian border. There are a lot of hazards along the way that can cause hikers to drop out and fail to finish – including blisters, running out of money, running out of time, deep snow, diarrhea, boredom, and forest fires.

I try to spend time on the PCT this time of year and will often photograph thru-hikers and post the photos on my flickr page.

PCT Thru-hikers

In addition to trail running on the PCT I am also an “armchair traveler,” meaning I’ve read a bunch of books about thru-hiking the PCT, including:

Cactus Eaters by Dan White – probably the best written PCT book and my most recent read.
Cascade Summer by Bob Welch – a middle aged Oregon newspaper writer hiked just the Oregon section. This might be more my speed.
Wild by Cheryl Strayed – the most well known and popular PCT book that will undoubtedly get more people on the trail. Also a well written and engaging read.
A Blistered Kind of Love by Angela Ballard – fascinating dual journal by a couple thru-hiking the PCT. It was interesting how the different genders report their trail experience. The male writes about where they went and what they did, and the woman writes about how she feels.
Skywalker – Highs and Lows on the Pacific Crest Trail by Bill Walker – the most endearing and charming PCT book ever.
Pacific Crest Trail Hiker’s Handbook by Ray Jardine – groundbreaking and controversial – Ray clearly changed the way people approach long distance hiking.
A Long Walk by Hap Vectorline – a whimsical journal of a partial through hike that started at the Canadian border and made it as far as Oregon.
In addition to the books I read various PCT blogs, and many of the youtube videos as well.

Hikers

My dream is to someday thru-hike the PCT – but I don’t think it will ever happen for a number of reasons. I’m certainly in good enough shape, and strong enough, but at 53 am I too old? I don’t think so – I’ve met plenty of thru-hikers that were middle-aged. They tell me they are slower and have to leave earlier and hike longer to keep up – but that would be no problem. I think hiking for that long on anticoagulants might be an issue. On Pradaxa falling just isn’t what it used to be! The main problem is, of course, finding the time. I work full time and just don’t have the resources to take six months off from work.

Maybe some day I could just thru-hike the Oregon section. Or maybe just the Sky Lakes Wilderness (fifty-one miles) – that could be done in a weekend. Why not?

Ringo Dingo

But I still love running in the Sky Lakes Wilderness. As far as falling out on the trail and bleeding out, or having a stroke out there, or being eaten by a bear, or whatever, I like to say that I’d rather die in the Sky Lakes Wilderness than in the Sky Lakes Medical Center.*

*Our local hospital, where I am on the surgical staff, is the Sky Lakes Medical Center. I like our hospital – I’m just saying that I’d prefer to die with my sneakers on, so to speak.

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A Fib Runner – Distance Running and Mountain Biking With Atrial Fibrillation

A blog about atrial fibrillation and trail running, ultra running, mountain biking, and other endurance sports.

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