It is strange but true: amateur sportsmen who lead an active lifestyle and follow a dietary plan fall into a high risk group in terms of numbers of infarctions and unexpected cardiac standstills, even though it is physical exertion that not only helps in heart disease prevention but also constitutes an important component of rehabilitation after infarction. How to train sensibly? And, if illness becomes unavoidable, how to regain one’s health? These issues are highlighted in our interview with Doctor Christian Marc Schmied, a leading specialist on sports cardiology.
– Doctor Schmied, is it true that people check their car engine more often than the health of their own heart?
– It sounds silly but it’s true. Several years ago, my student and I held a small experiment in the greater Zurich area. We asked the locals the same question: “Is everything okay with your heart?” Only about 10% of respondents said that they were considering an examination. The rest were not concerned at all.
– But the thinking of the majority is understandable: nothing hurts, hence everything is fine. Moreover, if a person does sports, follows a meal plan… However, statistically, not everything is so encouraging, right?
– French scientists did research where they compared the frequency of sudden cardiac arrests in professional sportsmen, amateur sportsmen, and ordinary people. Approximately 90% of cases were with hobby sportsmen. Their average age was 45; nine out of ten were men. It means that active middle-aged men are particularly at risk.
– It sounds like sport is injurious to health.
– Of course not. Moreover, it is necessary to do sports both before and after an infarction. But it is also important to bear in mind that intensive exertion may be harmful, particularly in the case of an underlying cardiovascular disease or even for healthy individuals that lead a sedentary lifestyle and increase their training intensity too fast.
– Why do active young men experience heart problems for no obvious reason?
– Usually, there are no specific symptoms. A person feels fine and does not notice that he has got an underlying cardiovascular disease. This may manifest itself as, for example, mild depositions, or so called “plaques” on the blood vessels. Nevertheless, this can become a cause of complications, sometimes fatal, when the plaques rupture and consequently start a cascade and, by virtue of the body’s reaction, the vessels encounter occlusion. To avoid this, it is necessary to control cholesterol levels in particular and to have the blood analyzed in a timely manner, although many people think that levels of cholesterol in the blood are exclusively attributable to lifestyle. Consequently, someone who observes all the necessary preventive measures may feel that he need not be concerned. However, this is not the case. There are situations when a person eats healthy food, does not smoke, and plays sports, but, all of that aside, he has a genetic predisposition to vascular diseases and all that they may entail. It is very important, particularly after the age of 25–30, to undergo an examination in order to see if you are at risk. If high cholesterol is discovered, you will get a prescription and an additional examination. Nevertheless, although certain fatal events may not be attributed to plaque ruptures, younger individuals should undergo regular cardiac screenings to detect underlying hereditary cardiovascular disease.
– What must be examined in order to assess the state of the heart?
– Beside a thorough physical examination I would recommend a resting ECG, an exercise test and a heart ultrasound investigation, and a blood analysis. If a high risk of heart attack is found, further examinations are warranted (i.e. computer assisted heart tomography). If plaques are found on the vascular walls, it will be necessary to mitigate the risks by medication.
– How long does it take the patient to undergo such an examination?
– About two hours. The physical examination, ECG and exercise test will take about one hour, and the ultrasound investigation will be one more hour – although, as I said before, blood analysis will possibly be needed, as well as heart tomography, so that will take some extra time too. On the other hand, if a patient comes to us with external analysis results, it will considerably speed up the process.
– In principle, may such examinations be easily combined with a vacation?
– There are two basic options. A patient brings us his existing results and everything else will take him two hours. Alternatively, he may undergo all the examinations here and get the results the next day or by the end of the vacation.
– If high cholesterol and vessels occluded by plaques are found, does one have to give up sports for a while?
– Sport may and must always be practiced. The results of the medical examination will help assess the risks and we can compile a training program accordingly. Moreover, physical exercise specifically represents an important part of primary prevention as well as the rehabilitation program after infarctions and other heart diseases.
– And what about the widespread opinion that rest is vital after a prior infarction?
– There are hundreds of research documents proving that physical training is a crucial part of the treatment. It is as important as medication and other rehabilitation procedures. An examination is necessary to assess the risks, to rule out re-infarction or cardiac rhythm disorder, and to find the kind of sport that will be the most useful for the patient.
Therefore, in case of prior infarction, the upper limit of exertions must not be exceeded. It is no less important to do the kind of sport that is attractive to the person in question, whether it is jogging, soccer, table tennis, or Nordic walking. We should compile a training program which includes different kinds of activities. I will reiterate that each patient must be considered individually.
– What should an up-to-date rehabilitation program look like?
– It’s a good question. Earlier, a survivor of infarction had to stay in bed for a long time in order to safeguard his heart. Nowadays, it’s the reverse – the patient gets up out of bed on the same day or soon thereafter and little by little learns to increase physical exercise while he is in the clinic. As for the rehabilitation, there are two options available – outpatient or inpatient care.
The inpatient rehabilitation lasts 3–4 weeks and the outpatient rehabilitation 3 months, during which time the patient visits the clinic 3 times a week (the visit takes from 60 to 90 minutes). Both methods are equally effective, and each of them may be adjusted for a specific patient. Some prefer spending time in a clinic, where they are provided with proper care; others feel more comfortable when they are back in familiar surroundings.
These methodologies will be beneficial for both survivors of infarction and patients with chronic heart diseases. Our rehabilitation methodologies prevent emerging infarctions and sudden fatalities. This is already proven.
– Are there any kinds of sport that are forbidden if a person has had a heart attack?
– Much depends on the situation. If the heart’s vessels are affected, then of course there will be limitations, but if the heart function recovers and the blood supply is restored, then, as a rule, we allow all kinds of sports. You may even run a halfmarathon or even a marathon. But let me state this clearly once again: The patient has to first undergo a thorough evaluation by an expert and then an individualized recommendation can be made.
– I recall a well-known anecdote: “Before the operation I could not…”
– Of course, I mean those who do sports regularly. There are people who sit at a computer all week and then during the weekend they strain themselves. This is wrong and even dangerous. It is also dangerous if exercise is accompanied by emotional stress. Speaking of marathons, there is one very interesting piece of research in which American scientists observed marathon runners. The number of fatalities was negligible for almost the whole distance until the final 10 km – this was the stretch in which the majority of fatalities fell. I explain this by the fact that the runners, having covered the greater part of the distance, are physically and emotionally exhausted yet nonetheless they are not willing to give up and instead they extend themselves with too much effort. And this strain is the cause of the tragedy. The same thing happens at work. When it seems like you are on the edge but still go on with the work because the success of your project is imminent, your heart experiences exertion comparable with the final kilometers of a marathon. In other words, whatever you do, it is important not to get overwhelmed. You have only one heart and one life.
– In fact, in order to stay out of danger, one needs to arrange an appointment with a cardiologist and devote two hours to the examination. These two hours may save your life in the future. For instance, I am going skiing on my winter holiday in Zermatt, and I undergo an examination on the way, and the next day or on my way back, the doctor informs me of the state of my heart. Is it that easy?
– Absolutely right. The University Heart Center Zurich is easily accessible and within the next few years a university medical center will open up at Zurich airport. We do our best to be as accessible as possible to people and help them prevent diseases.
Christian Marc Schmied
Doctor of Medicine, Leading Consultant at University Heart Center in Zurich, Head of Sports Medicine/Sports Cardiology and the Cardiology Outpatient Clinic at the University Hospital of Zurich. He studied medicine at the Medical School of the University of Zurich. He is actively cooperating with professional athletes together with his work at the University Hospital of Zurich. He is one of the team physicians of the national team of Switzerland in alpine skiing and of a local professional hockey team. He has been Medical Advisor to FIFA since 2006. He has held the position of an associate editor of the European Journal of Cardiology since 2009. He has been a nucleus member of Sports Cardiology Section of the European Society of Cardiology since 2013 and he lectures at the Swiss Federal Institute of Technology and the University of Zurich.
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