Heart Screening
The modern era of triathlon begins, for me, with John Mawdsley. Almost none of you reading will remember that name, but I do and I will because of the starkness of his experience. John Mawdsley died in 1995, during the swim at the Chicago Triathlon. He left a wife, and a 7 year old son, and a 10 year old daughter. Assuming providence, they are now 24 and 27 years old and they spent their teenage years, and continue to live, without their father.
Because of what I’m reporting on today, it might seem odd to bring up the memory of this man, because I cannot find any indication of heart disease or cardiac arrest associated with his death in that race. And it is also arbitrary that I assign the “modern era” with his death, because a year before 39 year old Mr. Mawdsley died in that race 42 year old Mike Lanham died in a Chicagoland race. Mr. Lanham did not die in the water, rather of a heart attack shortly after exiting the water.
I attach personal significance to Mr. Mawdsley’s death for the following reasons. First, I was at that Chicago Triathlon and I annually visited that race, either to work it or to race in it myself. Because of that, his death struck me more personally than if I had simply read about it from afar. Second, I was in the wetsuit business as the time, and while contemporaneous accounts of Mr. Mawdsley’s death read that “Mawdsley had been specifically training for the swim for several weeks and had swum the distance of the race — about nine-tenths of a mile — a number of times,” (Chicago Tribune, quoting a Mawdsley family spokesman), I remember hearing that Mr. Mawdsley purchased a wetsuit from an expo vendor the day before the race.
This was the first I’d ever heard of anyone dying in a wetsuit in the swim and, while the wetsuit Mr. Mawdsley used was not ours, it was an annual ritual at that race for hundreds of wetsuits to be sold the day before the event, for use in the event. We were always very fastidious about how our wetsuits fit, and how they should be used, and I personally would not hesitate to use a wetsuit for the first time in a race. But I am not naïve to how wetsuits should fit and what wetsuits should and do feel like in the water. When provided a binary choice — swim in cold water, in open water, for the first time (or the first time in a long time) in no wetsuit; or swim in those conditions with a new, never used wetsuit, by someone not used to swimming in a wetsuit — I still think I’d choose the latter, if I knew that the wetsuit seller was adept at fitting the swimmer properly, and had that proper wetsuit size and model in stock. My preference is not to face that binary choice, rather to see these wetsuits sold weeks before a given use in a race.
There was about a death a year in the U.S. In triathlon in the decade preceding John Mawdsley’s death 17 years ago, including deaths in and out of the water. We’re now in the neighborhood of about a dozen deaths a year over the past 2 years, most of them in the water. Now, to be sure, the sport is a lot bigger than it was in 1995. A lot bigger. The decade of the 90s was not a high spot for triathlon. Our big decades were the 80s and the aughts.
Maybe this is a good time to reflect on what we as a sport might do differently. Most of this has been covered in previous installments of this series, and I hope athletes and race directors can join together to commence preparation for triathlons weeks and months in advance, rather than buying a wetsuit at the race expo and jumping in open water for the first time when the gun goes off, as is so often the case.
As a part of this commitment to race readiness I’m going to report on a program that is already causing a lot of hand wringing even before its launch. A cardiology practice in Santa Monica will screen triathletes in its office, setting aside appointment times during the afternoons of the next several Tuesdays and Thursdays. This screening will consist of a document querying any family history of heart disease as well as questions about notable symptoms and warnings. The patient will undergo a physical cardiac exam along with an EKG and lipid panel. The aforementioned will cost a flat fee of $150. Should further testing be indicated as a result of the front line exam, stress EKG and echocardiogram tests – if indicated – will cost a flat fee of between $75 and $100 each.
Why would this possibly be controversial? Because a large subset of cardiologists view screening in a way similar to PSA and mammogram testing, that is, the harm caused by false positives outweighs the benefit of mass screening. These cardiologists think it’s dubious how many if any lives can be saved, while dozens could be harmed through unnecessary and/or invasive procedures that carry with them their own risks, and this is separate from the expense incurred that these cardiologists consider better spent elsewhere (I don’t want to put words into their mouths, but, I think they’d say you’d probably be better off getting a colonoscopy if you’re 50 and have not had one yet).
Further, the American Heart Association feels that screening beyond the answering of 12 specified questions is not indicated. However, my sense is that the AHA makes this recommendation in the context of true mass screening, including all high school students that are involved in sports, and a number of annual screenings might reach or exceed 5 million. In this context, yes, both the cost and the potential problems resultant could be problematic. Still, I hear loud and clear the view that the screening we're reporting on below may solve problems, yet it may also incept problems.
Those favoring screening point to the experience in Italy where, for a generation, such pre-competition screening is mandatory and has caused sudden cardiac death in exercise in Italy to fall by almost an order of magnitude. However, those in opposition to mass screening point to a specific – and identifiable through screening – genetic problem in a region of Italy that is responsible for a significant number of that country’s sudden cardiac deaths, and that congenital heart anomaly is not typically found in Americans.
I acknowledge the tension between the competing narratives. I don't know which voices are, on balance, the wisest.
Last week I was talking with a good friend of mine who has been with me in triathlon’s foxhole for the past 3 decades and more. Murphy Reinschreiber remembers finishing his noon swim workout early because he was not feeling well. He got from the locker room to his car, and sat there, sweating profusely, with tingling in both arms. He got out his cell phone and pushed the buttons: 9-1-1. He could not push SEND. Not because he was physically unable, but because he did not want to trouble the emergency system with a false alarm. He did not know who to ask. He did not have a GP. He did not know a cardiologist. He just did not know what to do, where to turn, who to call.
Murph called his wife Shannon. He was lucky she answered; it was she who dialed 9-1-1. Murph was having a heart attack, and did not know it. A stent later Murph is back in the pool, back in the 1:15 lane, and he has dinner each night with Shannon and their family. What concerns me about this story is that a very bright, very shrewd, very talented, educated man did not know what to do at a very critical moment.
What tilts the scale in favor of this program – for me – is not simply the screening, but the establishment of a relationship. Triathlon is aging. We, its exponents, are aging. I’m in Kona’s Class of ‘81, and when Tinley, Molina, Monty and I raced that race were were 22, 23, 24 years old. Add 32 years to that and that’s how old we are today. A lot of us who started in the 80s are in our 50s and 60s. The mean age for triathlete has crept up and is now somewhere in the range of 41 or 42. If you take the raw numbers of deaths in triathlon and you filter for age, those who are 45 years old and up are more vulnerable. We should have our doctors’ numbers in our smartphone contacts.
If you have a relationship with a general practitioner right now, and especially if you have one with a cardiologist, I cannot see any good reason why this program would be of any use to you. If you do not have any such relationship, and if you are in the West Los Angeles area, and this program represents to you a low-cost way of adding a layer of comfort to the process of being a triathlete, then, printed below is an outline of the program rolled out for those athletes in West Los Angeles. Slowtwitch will spectate this program, and we may announce the launch of similarly-styled programs in other metro areas.
What you’ll read below is from Pacific Heart Institute, and for what it's worth my intersection with this group wasn't via a Google search, rather it stems from an "extremely strong" recommendation from Dr. Ramin Modabber, my orthopedic surgeon, the race doctor for the Amgen Tour of California, an avid road cyclist himself, who has been an integral part of caring for endurance athletes – recreational to elite – since he joined the Santa Monica Orthopaedic and Sports Medicine Group in 1997.
APPOINTMENT SCHEDULING, AVAILIBILITY AND TIME REQUIRED
The athlete should call 424-238-1784 and identify him- or herself as interested in the athlete screening, leaving call back information if you hear voicemail. After signing up, the screening questionnaire will be sent to the athlete by email, fax, or mail as preferred. The completed questionnaire should be faxed back to 310-829-6889 before the visit, and brought to the appointment as well. The screening is not intended for individuals with known or established heart disease.
Appointments will initially be available Tuesday and Thursday afternoons. If there is sufficient interest, Saturdays will be scheduled. The visit will be approximately 45 minutes for the basic screen, with an additional allowance of 15 minutes for the echocardiogram screen, and 30 minutes for the treadmill screen, if these are scheduled at the same time. Running gear is needed if a treadmill is scheduled. If after reviewing the results of the initial screen, an echocardiogram or treadmill is recommended, these will need to be scheduled at a later time.
BASIC SCREENING FOR ALL PARTICIPANTS $150
The basic screen is appropriate for athletes of all ages, following the guidelines of the AHA, with a questionnaire and brief cardiac examination by a cardiologist. It also includes an EKG and cardiovascular lipid blood test which will be reported several days after the visit. The screen includes a 10-year heart attack risk calculation based on the highly regarded Framingham database. The EKG will detect approximately 90% of hypertrophic cardiomyopathy cases as well as electrical abnormalities. If the EKG is abnormal, a screening echocardiogram may be indicated (approximately 25 percent of the time in the Italian endurance athlete screening experience).
TREADMILL SCREENING $100
We recommend that men over the age of 40, and women over the age of 50, also consider having a treadmill stress EKG. This consists of graded exercise with continuous monitoring of the electrocardiogram revealing the rhythm and evidence of restricted blood flow, with frequent blood pressure checks. As a screening test this is imperfect, and can have both false negatives (does not show a real problem) and false positives (shows a problem when none is present). If a falsely positive test is suspected, further testing with a stress echocardiogram or nuclear perfusion study is usually indicated. This would then not be part of a screening program, but would be covered by the athlete’s medical insurance.
ECHOCARDIOGRAM SCREENING $75
Finally, we will offer a screening echocardiogram. This test can be considered by an athlete of any age. It is the only simple means of detecting ascending aortic aneurysm (enlarged aorta), and the most sensitive for detecting thickened or weakened heart muscle, differentiating hypertrophic cardiomyopathy from the athletic heart, and seeing valve problems. This test is increasingly used to screen professional athletes because hypertrophic cardiomyopathy is a leading cause of athlete sudden death , but cost often precludes a recommendation for widespread screening. If significant abnormalities are detected, a complete echocardiographic examination would be indicated, covered by the athlete’s medical insurance.
The screening evaluation will be provided in a professional medical practice by highly trained and experienced personnel that are involved diagnosing and treating a broad spectrum of heart disease on a daily basis. We are not a screening company. We are offering this evaluation as a service to the triathlete community.
CONTACT INFORMATION
Pacific Heart Institute
2001 Santa Monica Blvd.
Suite 280 W
Santa Monica, Ca 90404
310-829-7678
