Mountain Biking and Atrial Fibrillation

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Mountain Biking in Oregon – Waldo Lake Trail

I’ve just returned from a nearly three-hour long mountain bike ride, so I thought it would be a good time to write about mountain biking while in persistent atrial fibrillation (this discussion is pertaining specifically to persistent A fib meaning I am always in atrial fibrillation and don’t ever expect to NOT be in a fib; I think people who have episodes of paroxysmal atrial fibrillation are going to have a different result).

One of my main concerns when I was first verified to have persistent atrial fibrillation was whether or not would be able to continue mountain biking. I started road riding in the early 80s, back when I still lived in the Midwest. When I moved to Klamath Falls, Oregon in 1987 I began mountain biking. This is a great place to ride, and we have a terrific trail system at Moore Park, as well as a couple of local high mountain singletrack trails that are legal for mountain biking (Brown Mountain Trail, Rye Spur Trail). I feel real connection to these trails and have been riding some of them for over twenty-five years.

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Rye Spur Trail, Klamath County, Oregon

I didn’t use to run is much as I do now, and back in the late 80s and early 90s I would pretty much mountain bike five or six days per week. I have developed some good bike handling skills, especially since in the early days there was no front or rear suspension, and nobody really knew what they were doing anyway. We pretty much plunged our quick release seat posts down into the frame, switched to granny gear as soon as we hit dirt, and would (inappropriately) lock up our back wheels and skid down steep hills – very much discouraged in this modern era. But that’s the way it was – skills develop over time.

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One of my old mountain bikes

At any rate I have developed good skills – skills specific to these particular trails, seeing that I generally know every rock and anticipate every little drop off.

There are two issues with mountain biking and atrial fibrillation. The first, obviously, is that my cardiac output is reduced by about 15 or 20%, so naturally I am a little bit slower. People get slower when they get older, too, so there’s that to deal with as well. But the real issue, I think, is the fact that I am on a potent anticoagulant – Pradaxa. One of the disadvantages of Pradaxa is that it works really well (but the real disadvantages that it does not have a reversal agent). Clearly – there is a risk of bleeding associated with crashing your mountain bike on the trail.

I sort of doubt whether Coumadin is that much safer than Pradaxa as far as this is concerned – while it is true that there is a reversal agent for Coumadin, what is the likelihood that, if I had a major crash, I would be able to get to the emergency department in time for them to give me the reversal agent? I generally ride alone, and our trails are pretty remote. It would take a while for me to get out of there, especially if I was bleeding all over the place, or even worse, if I were bleeding into the space previously occupied by important parts of my brain.

Over the years my skills have improved and my style has changed quite a bit. At age 53 I’m no longer much of a daredevil (I never really was). Back when I was thirty and was riding about five days per week, I estimated that I had one minor crash per week, and usually one major crash per season. In all that time I think I’ve only actually hit my head once (I definitely recall a bleeding ear after crashing on a technical descent on a trail called Garbage – never liked that trail).

I have always felt that all of your instincts and reflexes are directed toward protecting the head. It’s automatic.

Of course I have worn a helmet when bicycling since 1983. I even bought a new helmet when I went into atrial fibrillation and started anticoagulation. It fits better than my old one and it’s florescent green, so hopefully I have less chance of being run over by a pickup truck.

The only time I have ever had a significant bleeding problem while mountain biking was back in 1990. I came off the trail ride and was heading around the paved road at Moore Park to the picnic area to get some water when some young guys in a pickup shouted at me, “Wrong way, dude!” I didn’t yell back at them, but I turned around and glared at them as I zipped down a little hill to the picnic area, giving them a look that said, “You talkin’ to me?” I was going pretty fast at that point and hit a speed bump that sent me skidding across the pavement for a while.

I bet those guys were impressed.

Anyway, I had a lot of road rash, was just goes with bicycling to a certain extent, but the worst thing was I had a “degloving injury” on the side of my abdomen. What that means is that part of my skin more or less stuck to the pavement while the rest of me kept moving and the skin was pulled away from the underlying tissue. It didn’t break all the way through the skin, but I developed a hematoma the size of a baseball right where the “love handle” would normally be. Twenty-three years later it’s actually still there to a certain extent, not the blood, but a big lump of scar tissue beneath the skin, and the skin over that area is still kind of numb.

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Klamath Ridgeview Trail – Moore Park

That happened with no anticoagulation – I never even took an aspirin back then. If I had a similar injury now that would’ve been a major hematoma – I might even need a transfusion.

That’s the risk. Falls are part of riding a mountain bike. I’ve been on Pradaxa for a year now and I think I’ve only had two crashes. I am so much more cautious than I used to be that I rarely ever crash, and when I do crash it usually something stupid like having mud or ice in my pedals and not been able to click out when stopping, falling over like Artie Johnson used to do on that tricycle on Rowan and Martin’s Laugh In. I honestly can’t say that I’ve noticed more bruising or bleeding than I would expect prior to Pradaxa. So far, so good.

I feel it is important, however, that when you’re cardiologist tells you that you probably shouldn’t be mountain biking that you do what he says. Don’t be like me. Don’t disregard your cardiologist advice. Do as I say, not as I do.

All joking aside – there is a certain risk and if you can accept that level of risk, then continue mountain biking. If not, stay off the trails.

As far as how much persistent atrial fibrillation affects my climbing, well, when I first get started it is quite difficult. After I warm up it really doesn’t seem like it’s any different than not be in atrial fibrillation. Recall that I do not take anything like a beta blocker or an antiarrhythmic – if you take medications like that your experience may definitely be different. All I take is the anticoagulant.

I’m slow, definitely slower than I was twenty-five years ago, but it almost seems like it’s within the realm of what you’d expect from being that much older. Like I said in the article about running in atrial fibrillation, it’s almost like you’re a pickup truck with a four speed manual transmission, but you can only use second and third gear. But you can still have a lot of fun in those two gears! It just takes a while to warm up.

Personally I think road biking is more dangerous than mountain biking, as far as bleeding risks are concerned. All my best crashes have been on pavement, including my best mountain bike crashes (see above). And pavement is usually where cars, driven by people who are talking or texting on smart-phones, hit you.

As far as endurance and energy output are concerned road biking, by its very nature, is easier to do in persistent atrial fibrillation that mountain biking. On a road bike you get into a groove, and have a certain steady energy output. That’s perfect for atrial fibrillation. Anybody who trail rides, especially on technical, steep trails, can tell you that mountain biking consists of a little burst of energy here, then a little short, brief period of rest and recovery here (by slow pedaling for a couple of seconds), and then hammering the pedals again to get over the next little obstacle, or whatever. That’s what’s fun about it – it’s almost like doing a puzzle. Trail riding involves a lot of little, short, anaerobic bursts of energy – and of course atrial fibrillation has diminished this ability, as far as I’m concerned.

Although, speaking strictly of endurance, I don’t think that is changed too much since I went into persistent atrial fibrillation. I can still ride for just as long as I used to be able to ride. I have found that while I have lost speed with age I have gained endurance in spite of atrial fibrillation.

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Moore Park Mountain Bike Trails

I am very interested in other mountain bikers’ experiences with atrial fibrillation, especially athletes who take rate control or anti-arrhythmic medications. Please feel free to leave comments – Thanks!

Heat and Salt and A Fib

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

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Pre-Race Motel

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

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Pre-Race

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

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

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

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Resting During a Trail Run

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

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

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Ringo – Pooped Out After a Long Trail Run

Persistent and Intermittent Atrial Fibrillation

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

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

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

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The Best Mile Marker

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

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

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

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

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

Intro – Atrial Fibrillation and Endurance Sports

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

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

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

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

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

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

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

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

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

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

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

What Is Atrial Fibrillation?

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

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Atrial Fibrillation in Athletes (In a Nutshell)

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

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Getting Ready to Run on the PCT

Pradaxa and CHADS2

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

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Some of my Pradaxa

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

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

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

CHADS2 on Wikipedia

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

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

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

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

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

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

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

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

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

What Activities Are Safe While On Anticoagulants?

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

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Klamath Falls Mountain Biking Trails – Hot Lava

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

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

I don’t ride like that.

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

bridge to nowhereArchery Trail – Bridge to Nowhere

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

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

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

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

This is not what I do!

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