Re A-Fib: 5 Things I’ve Learned in 10 years… A Guest Post by David Grayson Lees

Posted on April 22, 2015 by michaelpmccullough

I’m a 64 year-old road/trail runner, marathoner and weight lifter diagnosed with atrial fibrillation more than a decade ago. I’ve had three ablations and as many cardioversions, plus I’ve swallowed the usual assortment of prescription meds. Now my a-fib has become paroxysmal atrial flutter—about one episode every two weeks or so, usually lasting a few hours—and while my running days seem to be over, I still regularly make it to the gym and I’m discovering the joys of walking and hiking.

Through trial and error—plenty of each, actually—as well as a fair amount of research, I’ve come to a handful of conclusions that may be useful. While I believe them to be true, keep in mind that my observations are true for me; your experience may well be different. Finally, since I’m not a physician, nothing here is intended as medical advice.

And now: 5 things I’ve learned in 10 years of dealing with the always-entertaining world of cardiac arrhythmia.

A-Fib won’t kill you…even though a diagnosis of a-fib—and its symptoms—can be very scary, barring underlying cardiac disease, a-fib is not inherently life-threatening. And so if you have just been diagnosed, relax as best you can.

…but a stroke could. Pay rigorous attention to your anti-coagulation regimen. Even if your CHAD score is zero, at least take a low-dose aspirin every day. Personally, I find Coumadin to be a true pain, what with blood monitoring, dietary restrictions and the like. I much prefer the newer meds, especially Xarelto. It acts quickly, and as an added bonus you don’t have to be continuously concerned with your INR numbers.

Your EP isn’t interested in prevention. Typically, EP’s are all about fixing stuff rather than prevention. Which is weird, because unless you’re on the younger side of 40 and/or your a-fib has been freshly discovered, one ablation usually won’t do the trick. Of course, I’m grateful to my two EP’s, one rated among the best in California and the other acknowledged as one of the best in the world. It’s just that neither one has ever expressed any interest in the contours of my life, including what my exercise habits happen to be, what sorts of supplements I take, or what my days are like. Now, I’m not looking for a new best friend, but it’s clear that for them I’m a unique problem to be solved rather than a unique human being. I’m not angry about it; after all, these docs chose a field in which their major interaction with patients occurs when the patient is unconscious.

Still, I believe the implication is clear: you are pretty much on your own when it comes to figuring out how to modify your life style, exploring vitamin/mineral supplementation, and gathering the latest non-nutsy information.

(BTW, in terms of info, two websites I recommend are Dr. John Madrola and The A-Fib Report. Dr. John is a younger EP who always has a thought provoking take on new developments in a-f treatment and research and The A-Fib Report is a readable compendium of international a-f research, written in lay language. It requires a nominal membership fee that’s well worth it.)

Supplementation could work for you. I haven’t thrown out my beta blocker (Sotalol AF, not regular Sotalol) but along the way I have had excellent results in controlling the frequency and duration of my atrial flutter episodes by supplementing with 200 mg of magnesium citrate in a pill taken at lunch and ¼ teaspoon of potassium citrate dissolved in water taken in the morning and again at dinnertime (Please note: ingesting too much potassium involves some quite severe health risks, so be careful.)

Life is good. But first, the bad news: as near as I can tell, nobody knows what causes atrial flutter. The gang of suspects spans endurance sports (!) to mysterious biochemical mechanisms that somehow encourage the formation of tissue substrates that make the electrical system of the heart go haywire. Researchers—and your EP, too–are just guessing, leaning on statistical correlations rather than employing demonstrable causal connections. Maybe cutting out caffeine will help you; maybe it won’t. Maybe abstaining from demon rum will prove to be the answer; maybe not. Obviously, if you are over-drinking, over stressing (like many of us who are into enduro sports) under sleeping or happen to be engaged in other deleterious deeds, changing your behavior is simply a good idea, a-fib or no a-fib. Just don’t expect that any one thing will be the answer.

The good news is, you can have a great life even with a-fib and a-flutter. No, I don’t love my a-flutter episodes; they are annoying and sometimes, even after a decade, still frightening. I don’t run anymore, but a long walk or a moderate—I know, I know, not my favorite word, either—hike turns out to be a lot of fun. No, I can’t put the same hemodynamic load on my heart that I used to, but I can still work up a nice funky sweat underneath the weight machines at the gym.

Besides, working out is only a part of life. My friendships, relationship with my son, work, and my love life (I’m getting married again, and I’m stoked!) are just as satisfying as ever.

Maybe more so.

Those of us with a-fib or a-flutter aren’t sick, not truly. Nor do we need to afraid.

So—live!

(Thanks to Linda for the inspiration. Thanks to you for reading.)

Update: Atrial Fibrillation, Pradaxa Fail, Transient Ischemic Episode, Blood Clot in Left Atrial Appendage

Posted on April 12, 2015 by michaelpmccullough

Ridgeview Trail – Moore Park

About two weeks ago I was out for my typical Saturday two hour trail run on Moore Mountain with my dogs. It was a fine day and I felt great, and with about ten minutes left in the run I ran into three of my friends who were out mountain biking. My friend Linda, a Physician Assistant, was trying out her fancy new mountain bike and we stopped to talk for a while. She showed me her new bike and I introduced her to my new dog. I noticed, and commented, that I was having a little trouble getting my mouth working properly. I didn’t have any trouble finding words, or even saying the words, but my tongue just felt sort of thick – especially with consonants like “R” that seem to be made in the back of the mouth. I immediately did my self inventory for asymmetry and muscle weakness and found none. I attributed it to having had one of those little, annoying white sores in my mouth, accompanied by some swollen glands and thought nothing of it.

Linda Cyclecross racing

I finished my run, which involved a fairly technical descent, ate my post-run Clif Bar, and went home where I noticed nothing amiss. I forgot about it until Linda texted me the following day asking how I was doing and saying she was worried about me. I assured her – I was fine!

The next Monday, at work, I thought I’d ask my friend and co-worker, Dr Zakir Ali, if he thought the incident was any reason for concern. Dr Ali is a neurologist who works a couple of days a week at the orthopedic clinic, where I work as a podiatrist.

He wasn’t as dismissive as I was about the incident and said that that was very suspicious for a TIE (transient ischemic episode). A TIE is basically a small, brief stroke, in this case likely caused by a small blood clot that resolves fairly quickly. Dr Ali said I should, at the very least, get an echocardiogram to see if there is a clot in my left atrium, and possibly a carotid artery scan as well.

I have been in permanent atrial fibrillation and on Pradaxa, a potent anticoagulant (blood thinner) for two years and had never missed a dose. I thought he may have been over reacting – and I had had an echocardiogram just two months ago.

But Dr Ali had told me, “You will never regret checking.”

And I agreed.

Okay.

So I called the on call cardiologist, explained what had happened, and he told me a standard echocardiogram would be useless as it won’t show a clot, and recommended a trans-esophageal echocardiogram, and also a carotid scan (ultrasound).

I mentioned that I had had a trans-esophageal echocardiogram before (in 1994!) and it was like swallowing a telephone. He said he’d get anesthesia involved and we set up both procedures not expecting to find anything.

So the carotid scan came first and was normal, as expected.

Last Wednesday I went to the hospital and checked in to Day Surgery – which was a peculiar and strange experience for me. I’ve been working there, as a surgeon, for the past twenty-five years, but this was my first time being there as a patient. It’s a little disorienting, and oddly embarrassing, to be on “the other side of the door.”

Anyway – Dr Vince Herr, the anesthesiologist, gave me some propofol so I don’t remember a thing; but when I woke up I was told that I had a small clot in my left atrial appendage, and turbulence in my left atrium as well. This was a surprise for everybody involved. Judging from my lab work and the bruises on my arms the Pradaxa seemed to be working – but evidently not well enough! And that “small clot” looked pretty big to me – downright dangerous.

Trail Running on the PCT

At that point I was immediately started on Lovenox injections twice daily (for six weeks!), the Pradaxa was discontinued, and I am beginning to take warfarin (Coumadin); and of course I stay on the beta blocker (carvedilol). My cardiologist gave me the first Lovenox injection right in the post-op area.

Also it looks like no running or bicycling for six weeks – which of course is devastating to me, emotionally, but – shit! – blood clot / stroke / potential death – yes, I am definitely sticking with the program!

The injections are easy to do, they burn a bit but don’t really hurt, and every injection leaves a bruise. Believe it or not I enjoy and look forward to each injection because I’m hopeful that they will be helpful.

I’m disappointed that the Pradaxa failed – it is much easier to take that warfarin. Remember that I am a vegetarian and one of my passions is eating healthy food, especially kale. Also everyday, up until now, I eat a little square of nori (seaweed – like the wrapper on sushi) thinking that it would be a good source of iodine as I don’t eat any seafood or use table salt. Kale and nori are probably the two worst foods to eat if you’re taking warfarin!

Taking warfarin is going to be a real challenge – changes will be made, changes that actually seem sort of unhealthy. The one advantage is that warfarin is, unlike Pradaxa, reversible, which is a true benefit in the case of a bike or auto crash, a GI bleed, a head injury, and so on.

Moore Park Trails

In six weeks the trans-esophageal echocardiogram will be repeated and hopefully the clot will be gone. If not some sort of procedure (by the electrophysiologist) is in store for me. Hopefully I will 1.) not die and 2.) get back to trail running. Until then my nerves are wracked worrying about having a major stroke!

I need to say that I feel incredibly blessed – if I hadn’t met my friends and stopped to chat I never would have known I was having a TIE. And if Linda hadn’t have texted me the next day I wouldn’t have ever pursued it, because I had, in my mind, completely dismissed it. And also – how many people actually have a neurologist right in their office who is willing to talk at any time?

Clearly I’m not through this yet – but in a way I feel I have already dodged a bullet. Really, if it weren’t for Linda that blood clot would have just kept getting bigger and who knows what would happen next? I might be dead by now. Even as it is now – who knows? But at least now I know I have a problem and the treatment plan has been changed.

So thanks, Linda!

Me and Linda in Costa Rica

I would appreciate any comments, especially shared experiences, you might have.

To be continued. Wish me luck.

Atrial Fibrillation, Running, and Beta Blockers Part Two

Posted on February 16, 2015 by michaelpmccullough

The last article I wrote about beta blockers was written last Summer when I was more or less just starting the beta blocker. I had noticed a decrease in performance and exercise tolerance and when I went to the cardiologist and had an echocardiogram it was determined that my rate was going up and my ejection fraction was going down – that means my heart was pumping less efficiently and was pushing out as much blood with each beat. I was put on a low dose of carvedilol (6.25 mg twice daily) and it was thought that this would allow my ejection fraction (EF) to come back up.

When I started my EF was 55%, but when I had the echocardiogram mentioned above it was down to 45%. As noted in my last beta blocker article I suffered on runs and bike rides but felt it was worth it as I anticipated improvement.

When I returned for the follow-up echocardiogram I was extremely disappointed to learn that my EF had actually gone down to 37%. Not good.

At that point I the dosage of my beta blocker (carvedilol) was titrated up from the minimum dosage to the maximum dosage (50mg twice daily).

As you might imagine between the atrial fibrillation, the decrease in EF, and the high dose of beta blocker – running became extremely difficult. All three of these things decrease my cardiac output and, of course, that translates to poor performance. I now found I had slowed to a ludicrous pace, and honestly, running was starting to become a chore.

Running was starting to become unenjoyable; but I continued anyway.

I felt like every run was my first run after not exercising for several years, and I was walking up the most minor hills.

Last week I returned to the Heart Clinic and had yet another echocardiogram. To be honest I haven’t been feeling any better and runs still seem difficult so I decided not to even look at the screen or ask the tech about my EF as I assumed it was still poor. I’d just wait until the follow-up appointment with the cardiologist. But the tech, who knows me by now, just came out and told me – “Well, it looks like your ejection fraction is improving – it’s up to 47%.”

Well, that is good news. At least this suffering through the beta blockers is leading to some benefit.

That was just the preliminary reading, my new cardiologist (my previous cardiologist retired from clinic but still works at our hospital) interpreted the echo and said it was more like 50%!!! That’s nearly back to normal range (52-70%).

One interesting thing the cardiologist told me: she said that one would expect that people who are more athletic would have higher ejection fractions than non-athletes but in reality the opposite is often the case. I told her that my heart is so big that if my ejection fraction was too high there would be too much blood – ha ha.

There’s something I don’t understand about echocardiograms and atrial fibrillation – as anybody who is in a fib knows some beats are better than others. It’s easy to feel that – some are short and weak and others are longer and more powerful. How, when looking at the heart with the echo machine, can you tell what kind of beat you are having?

So there is some good news. Runs are still difficult and I don’t see myself ever being completely off of the beta blocker – but hopefully a different dose in the future when my ejection fraction reaches whatever the goal value ends up being.

In my next article on running and beta blockers I will discuss “Beta Blocker Blues” and the way this unpleasant medication makes me feel fatigued and, often, quite depressed. But for now I’ll embrace the joy of knowing my ejection fraction is significantly improving and will likely get even better.

Afibrunner: Patient Perspectives: Long-Distance Running and Mountain Biking in Permanent Atrial Fibrillation / EP Lab Digest

Posted on December 7, 2014 by michaelpmccullough

Patient Perspectives: Long-Distance Running and Mountain Biking in Permanent Atrial Fibrillation / EP Lab Digest

I am honored to have had an article published in the December 2014 issue of EP Lab Digest, a monthly journal for electrophysiologists and allied health professionals who work in electrophysiology labs.

The managing editor, Jodie Elrod, had approached me about writing a “patient perspective” article as she was familiar with my afibrunner blog. The article is basically a synthesis of material already presented in this blog, particularly my article called Atrial Fibrillation – A Visit to the Electrophysiologist.

I am delighted to have this opportunity to communicate with the EP community and promote my plea for empathy with respect to the endurance athletes afflicted with atrial fibrillation.

Thanks EP Lab Digest!

Also interesting – my cousin Chuckie, (an electrophysiologist – I’m sure they don’t call him “Chuckie” at work), who I mention in my article, had an article published in the November 2014 issue of EP Lab Digest.

SOB Trail Run 15K Race Report: Atrial Fibrillation, Running, Beta Blockers – My First Impression

Posted on August 13, 2014 by michaelpmccullough

SOB Trail Run

I have been in permanent atrial fibrillation for a couple of years now, but only been taking an anticoagulant (Pradaxa). But things have changed and for the past month I have been on a beta blocker, carvedilol.

Prior to starting the carvedilol, while in permanent atrial fibrillation, I had been able to run two marathons and one ultramarathon (50K) without any more trouble than the normal marathon type suffering, but over the past six months I have noticed things have been changing. I’ve slowed down, even for me, and distances are getting harder. My last half marathon was a joke and I was at the end of the pack within the first two miles. After a run or mountain bike ride of an hour or more I would have problems afterwards – my blood pressure would drop and my pulse would stay high. After a long run, especially if it was a hot day (which they all are, recently) I would get so light-headed after standing up I sometimes had to grip onto something to remain standing.

A visit to the cardiologist, and a subsequent echocardiogram, revealed that my heart rate was increasing and my ejection fraction was decreasing, and for that reason the cardiologist wanted me to start on a beta blocker.

A beta blocker, in this case carvedilol, is a drug that reduces stress on the heart by slowing the heart rate, decreasing the force with which the heart beats, and reduces the tone of the arteries throughout the body. The end result is that blood pressure is reduced, as is heart rate. The heart needn’t work so hard.

SOB 50 Mile Course – tough!

Some non-endurance athletes actually use beta blockers as performance enhancing drugs – it is said that it calms a person, reduces performance anxiety, and is commonly used in less endurance specific sports such as golf, target shooting, archery, and even in music performance.

Clearly these drugs are performance diminishing for endurance sports like distance running and mountain biking. We like to stress the heart, raise the heart rate, and we don’t have very much stress – we’re long distance runners after all – the mellowest people around.

I generally am in at least half marathon shape year round. Even if I’m not training for anything my weekend long run is going to be between nine and twelve trail miles. Prior to starting the beta blocker I had signed up for the 15K at the SOB Trail Run at Mount Ashland (Oregon) – one of my favorite races. This relatively high altitude run is basically all up and down trails and fire roads (zero flat sections) and I have done it at least six times in the past, including completing it twice in atrial fibrillation. I was curious to see how being on the beta blocker would affect my race.

DNF

The answer was I DNFed (did not finish) and dropped out fairly early in the race. That was terrible – most of my friends were running the 50K or the 50 mile and I DNFed the little 15K???

The course at the SOB is brilliant, really. A lot of trail races start out right away on singletrack, but the SOB has about a mile(?) of fire road at the start so everybody has plenty of time to figure out whether they are going to be running with the fast people or the slow people before they hit narrow Pacific Crest Trail. I ended up at the very back of the group that was running, but I was still in front of the few people who were walking the 15K.

I found that as soon as the course headed up hill I was unable to run. My chest felt funny – not chest pain, just felt weak, not right, and my legs felt dead. I wasn’t short of breath, I was just unable to do it. I decided, in my typical OCD mode, to continue running for five more songs on my iPod shuffle, and then turn around and drop out, thinking that I should at least get a little bit of a work out in, and that I could justify keeping the T-shirt I had paid extra for. I knew I could have walked the course, but that is not what I went there to do.

I was delighted that the fifth song on my iPod turned out to be an oldie from my high school days: Yours is No Disgrace by Yes. Not actually I song I still like very much, but in this context it seemed like a cosmic pat on the back.

http://youtu.be/Vd4jeeu90Rk
A Cosmic Pat on the Back

On the way back I met a woman who was also DNFing (sprained ankle) and we walked the last section of the race together, commiserated, and removed our numbers so they wouldn’t mistake us for the top finishers. At the finish line we informed the race officials that we had dropped out so they didn’t need to send a search and rescue team to find us.

DNFing and commiserating together as we remove our race numbers

So this article is, basically, my first impression of being on a beta blocker, in addition to the atrial fibrillation, and trying to remain an endurance athlete.

So far I feel that the beta blocker is more of a hindrance to my running and cycling than the atrial fibrillation alone had been – but then again, because of the atrial fibrillation my heart function is gradually diminishing.

I should say, on a positive note, that the beta blocker is working, and is doing what it is supposed to do. I check my heart rate and blood pressure at least once per day and since I started the carvedilol I am right where the cardiologist wants me to be. And I can understand why people who aren’t trying to be athletes might like the med – it seems to have a mild calming effect. Furthermore I no longer feel like my heart is a fish flopping around in my chest, and my post work out blood pressure and heart rate has stabilized.

I am optimistic that the carvedilol will be worthwhile and will help me preserve and regain my ejection fraction. But really, what choice do I have?

So here is how things have changed so far (compared to just permanent a fib without the beta blocker):

1.) As far as mountain and road biking is concerned I have been able to ride all the hills that I used to be able to ride, although I am much slower. My wife now has to wait for me at the top of a climb, and that’s fine. I am delighted I can still ride and don’t have to get off and walk my bike.

2.) Running is more negatively influenced. My previous slow pace is even worse, and hills are quite difficult. Not surprisingly I do not like this one bit. A slow jog feels like a 5K effort. But I am still able to run – Yay!

3.) Long runs in heat are not possible. I am just not able to do a long run in heat, and lately every day has been warm. Understand that I am a big red-faced Irish-American who considers anything over sixty degrees to be hot running weather; plus I live in a very sunny place, a high desert climate without a lot of shade. It is not surprising that this is happening. A normal person running in heat will have a higher heart rate for a given pace, and will need to slow down. If you are on a beta blocker that reduces the maximum heart rate by a significant amount, well: “game over.”

My goal is to continue running and mountain biking on trails like this: Brown Mountain Trail

4.) I suspect that the beta blocker might be making me lazy. I don’t know if that is the right word, but I had a full day off in the middle of the week a while ago and I had planned on, among other things, writing this article and going for a trail run, and next thing I knew it was late afternoon and I hadn’t done a thing. What? By that time there was a thunderstorm so I was not going out for a run – but the article still hadn’t been started. I hope this is not going to be the case from now on. Being lazy and depressed is far from my idea of fun.

I am going to wait until I have had more experience with the beta blocker and write a better informed article. I’m going to sign up for a relatively flat (downhill, actually) trail half marathon and try to redeem myself.

In the meantime I would love hear about other people’s experiences with the dreaded beta blockers. Please post a comment below.

Running with Atrial Fibrillation – It’s Okay To Be Slow! Forget The Pearl Izumi Advertisements

Posted on July 18, 2014 by michaelpmccullough

I saw some recent Pearl Izumi ads posted on The Trail and UltraRunning group on Facebook and thought I’d comment.

There are a number of Pearl Izumi ads that make fun of slow runners, here are two examples:

Pearl Izumi – Trying to sell shoes by denigrating slow marathoners

Divide and Conquer – Pearl Izumi teasing “joggers”

The remaining ads can be found on this excellent blog:

Short, Round, and Fast

One of the nice things about endurance sports, from half marathon and up, is that most participants do not have this type of attitude. It is a live and let live culture. It seems like half marathons in particular are a plce where you generally see conspicuously non-athletic looking athletes – and good for them!

Half Marathon Participant – Right on!

As for me, I’m in permanent atrial fibrillation, which makes me slow, and now I have to take a beta blocker, which makes me even slower.

But I’m certainly not going to stay home, and I’m going to remain a trail runner, even if I’m slow, and I still plan on signing up for distance events. At my last half marathon I was very surprised to see almost the entire field, including people who would previously never had been in front of me, pass me, get smaller, and disappear from sight. In the first two miles. Not fun. I was thinking, “Whoa, where’d everybody go?”

Contrary to how it might appear to faster runners who are observing slower runners, it’s not always easy being slow. It might actually be more difficult. Yesterday on a four mile trail run, my first run on the beta blockers (more on that later), I rounded a corner and saw another runner behind me. He was an individual who I had seen at the trailhead, who appeared to be a bit older than me, and who was wearing jeans and a long sleeved shirt on a ninety degree day. I thought, “Oh man, I don’t want to get passed!” and I cranked up my speed. I don’t think I was running fast at all, maybe about a ten minute mile, but the burning in my lungs and legs felt like a fast 5K. “This is ridiculous!” I thought, saddened. This is “fast” for me now.

But that is my new reality.

As far as Pearl Izumi is concerned they evidently think that being assholes, and creating some controversy, will make their ads stand out. They may be correct. There are a lot of competitors out there, they have an extremely small market share, and it is said there is no such thing as “bad publicity.” I knew that they made shirts, and jackets; but until now I didn’t even know they sold shoes.

Pearl Izumi Shoes – so fast you’ll kill your dog!

One of their ads last year, which featured a runner who ran so fast in his new Pearl Izumi shoes that he killed his dog, made quite an impression. Of course they apologized and had their (unfunny) ad featured in news stories and blogs for weeks.

By the way, my main nylon running jacket is made by Pearl Izumi. I like it, it’s a good jacket. I’m not going to boycott them or burn the jacket, or anything like that. I just want to say in this blog that slow runners are probably slow for a reason – and that reason isn’t necessarily poor character or laziness.

Me – Lazy jogger with atrial fibrillation after a twenty mile training run. I ran so slow that my dog survived!

Or even if the slow runner does have poor character, or is lazy, well, what’s it to you?

And guess what – Pearl Izumi got three of their ads posted in my little blog (and elsewhere) – for free!

Runner’s High – a Gift?

Posted on July 2, 2014 by michaelpmccullough

Is distance running therapeutic? Is mountain biking addictive? Is there such thing as a good addiction? If my atrial fibrillation worsens and I could no longer do long runs or bike rides – how hard would it be to kick the habit?

High Lakes Trail – Southern Oregon

Today in the hospital lounge, while I was eating some potato chips, somebody was telling me how bad potato chips are for me. Whatever – I have given up almost everything in the world that is bad for me. I haven’t drank alcohol in several years, haven’t smoked a cigarette in decades, gave up meat and eggs a couple of years ago, I’m almost dairy free, and I haven’t taken recreational drugs since high school in the seventies. Potato chips, which I feel are good enough to be “worth it,” are about it for me. Well, that and diet soda, which is also an unhealthy habit that I have.

But what about “runner’s high?” Is that my addiction?

And what exactly is runner’s high? Does it even exist? I’ve been hearing about it for a long time, even before I started running in the early 80s.

Allegedly the athlete’s brain is “flooded with endorphins, more powerful than any street drugs!”

Many distance runners claim to experience euphoria during or after running, and some claim they’ve never had it happen – not even once.

The endorphin theory is the oldest, but more recently I’ve read about how endocannabinoids (naturally occurring neurochemicals related, in a way, to the active ingredient in cannabis) might be the cause of runner’s high.

Another article I recently read attributes runner’s high to “dopamine, serotonin, and endorphins.”

Whatever the cause, it certainly appears to be real.

Pacific Crest Trail via Brown Mountain Trail – Klamath County, Oregon

Ultrarunner Dean Karnazes describes the role that running has in his life: “Some seek the comfort of their therapist’s office, other head to the corner pub and dive into a pint, but I chose running as my therapy”

“I’m convinced that a lot of people run ultramarathons for the same reason they take mood-altering drugs. I don’t mean to minimize the gifts of friendship, achievement, and closeness to nature that I’ve received in my running carer. But the longer and farther I ran, the more I realized that what I was often chasing was a state of mind – a place where worries that seemed monumental melted away, where the beauty and timelessness of the universe, of the present moment, came into sharp focus.”
― Scott Jurek, Eat and Run: My Unlikely Journey to Ultramarathon Greatness

Actually, a recent New York Times article states that on good experimental evidence it has been finally determined that exercise does indeed produce a flood of endorphins in the brain. Lucky us!

Researchers in Germany, using advances in neuroscience, report in the current issue of the journal Cerebral Cortex that the folk belief is true: Running does elicit a flood of endorphins in the brain. The endorphins are associated with mood changes, and the more endorphins a runner’s body pumps out, the greater the effect.

I won’t review the article here, but please read it – an elegant experiment, and solid conclusions.

But irrespective of the cause, what is runner’s high and what does it mean to endurance athletes? Can a person become addicted to it?

Personally I feel that the term runner’s “high” is a misnomer. I would describe it better as an altered state of consciousness rather than a high. Maybe I’m splitting hairs but I have never felt intoxicated by endurance sports.

Euphoria might even be too strong of a term – but maybe not. There are times during and after running when everything appears exceptionally crisp and beautiful. That’s why I love trail running, in Oregon, in the wilderness – does that happen to people in health clubs running on treadmills?

After an hour or so even carb gels seem remarkably delicious!

Also – music becomes intensely enjoyable. I do run with an iPod and sometimes I feel I am going back to the days back in high school when I smoked pot and would listen, chemically enhanced, to suddenly amazing music on headphones. Except now instead of sitting in a darkened basement I’m moving through the woods. It’s funny – a lot of the music that, for me, is most enjoyable on long runs, is the same type of music that I believe would be most enjoyable to a person who is stoned. Sometimes a song sounds so good I’ll repeat play a song two or three times.

But another reason I don’t like the title “runner’s high” is it isn’t all euphoria, beauty, and music joy. I think the exercise induced altered state of consciousness can involve a certain amount of emotional lability. Here’s an example: once I was on a twenty mile trail run, and at mile sixteen an old song I hadn’t heard in years, Careful With That Axe, Eugene, started playing in my random shuffle. This very early, nine minute long Pink Floyd song is sort of a novelty song; a one chord song that slowly builds on a rising and falling bass line with a mellow organ playing over it. At one point a whispering voice says, “Careful with that axe, Eu-zhene.” And then there is this horrific screaming and dissonant guitar, and finally it evolves back to the mellow bass and organ. Back when I was in high school, if we had somebody over who had never heard the song before, we’d put it on and turn down the lights, and of course when the screaming began it would scare the crap out of the first time listener, and we’d all have a good laugh.

Well I knew all about what was going to happen during that song and wondered if I would start laughing when the “axe” section came up. Imagine my surprise when I burst into blubbering tears when the screaming began. I should state that this was shortly after my ex-wife (with whom I was still friendly) and her family had died in a horrible house fire – but honestly I wasn’t even thinking about that until the screaming in the song. I know I wouldn’t have been anywhere near that emotional if I hadn’t just put in sixteen hilly trail miles.

Other times while running something will strike me as funny I will begin laughing giddily – out there all by myself, or in the back of the pack at a marathon. Or an angry song will play and I’ll feel, like, GRRRRRRR!, become angry – quite a catharsis.

GRRRRRRRR!

So is exercise induced altered state of consciousness addictive? I’m thinking: yes.

A CAGE questionnaire is commonly used to assess alcoholism.

Try applying it to your running:

C – Have you ever felt you needed to cut down on your running?
A – Has anybody ever annoyed you or criticized your running?
G – Have you ever felt guilty about your running?
E – Have you ever felt you needed a run first thing in the morning (Eye-opener) to steady your nerves?

Well – I can honestly say I’ve never felt guilty about my running, but the rest of those questions, well . . . .

And I can state for the record that with my atrial fibrillation, and the likely progression of my a fib, including my upcoming need to be on a beta-blocker, I have been dreading the day when I am no longer able to run. Very depressing.

Biking in A Fib – like riding through mud

Aside from that I have a theory. I think it is obvious that not everybody will experience anything like a runner’s high. Clearly many people hate the way running makes them feel, and they are the people who think distance runners are completely nuts. And why wouldn’t they? Based on the time they ran two miles and felt nothing but fatigue and pain, and interpolating that up to, say, thirty-one miles, their obvious conclusion would be “WTF?” to use the parlance of our times.

Lyon’s Trail – Lava Beds National Monument

But as for myself, and I’m guessing most of the people who would be interested in this blog, the so-called runners high can be generally considered to be a gift.

Diversion: How to talk to your children about distance running:

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.

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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.

Tag Archives: Trail running