Q&A on Athletes and Heart Disease: ‘You Can’t Run From Your Genes’

Despite their peak physical fitness, athletes aren’t eligible for a “get out of jail free card” when it comes to cardiac risk.

Eli Friedman, M.D., medical director of sports cardiology at Miami Cardiac & Vascular Institute. 

“Exercise and training are not immune therapy, as much as we wish that they were,” says Eli Friedman, M.D., medical director of sports cardiology at Miami Cardiac & Vascular Institute.  “My favorite thing to tell athletes, especially those with significant cardiac disease in their family, is that you can’t run from your genes. No matter how many miles you log, no matter how heavy the weights are, you can’t outrun those genetic predispositions. So, it’s really important to be aware of it and to seek attention certainly if there are symptoms.”

Sports cardiologists like Dr. Friedman have developed specialized approaches to heart care for professional and amateur athletes and those in physically-demanding fields like first responders. He talked about their unique cardiovascular needs during a recent episode of Baptist Health’s Resource Live program, hosted by Jonathan Fialkow, M.D., deputy director and chief of cardiology at Miami Cardiac & Vascular Institute and chief population health officer for Baptist Health South Florida.

An excerpt of their discussion is included in the Q&A below.

Dr. Fialkow: “Can you tell us a little bit about what sports cardiology is?”

Dr. Friedman: “As a sports cardiologist, first and foremost, I’m trained as a general cardiologist. But those of us who participate in this field, I think really find ourselves being very passionate about the intersection of cardiology and sport or athletics. We care for anybody to whom exercise or sport is important. That can be our weekend warriors, or those just exercising to attain the health benefits of exercise, all the way through our professional or Olympic athletes. (It’s important to) be able to speak the language of an athlete, to understand what makes a runner tick, what makes a cyclist tick, what makes somebody who’s a performance artist tick, and same with our first responders. And then understanding how the discipline that that athlete participates in can affect the cardiovascular system and what we call adaptive mechanisms.”

Dr. Fialkow:  “What makes the hearts of athletes different from those of non-athletes?”

Dr. Friedman: “The heart is a muscle, just like any other muscle in the body. And when you train it, when you participate in sport or athletics, especially for long periods of time, that muscle can adapt. It will change the way it looks. And that’s true both in how you look at it grossly, but also in the testing that we do. Echoes, MRIs, ECGs, et cetera. So, it really requires a lot of nuance, a lot of thought, a lot of time with our athletes to get to know them on really deep and detailed levels to then be able to provide care.”

Dr. Fialkow:  “What do athletes need to do to stay on top of their cardiovascular health?”

Dr. Friedman: “We want to get as many people exercising as possible because the health benefits are just so profound. Just simply meeting the guidelines of exercise, which is 150 minutes of moderate intensity exercise per week, or 75 minutes of high intensity exercise per week, will have significant cardiometabolic protective benefits in terms of lowering blood glucose, lowering cholesterol, lowering blood pressure, psychosocial wellbeing will improve as a result of exercise as well.

“Now, when we talk about our athletes, yes, the more you do, there will be some improvement in those risk factors as well. But it tends to have diminishing returns. Somebody who does an ultra-marathon one time per week is not tangibly going to be healthier than somebody who hits those guidelines.”

Dr. Fialkow:  “Do you find that athletes tend to ignore other risk factors that may exist because they’re athletic? What would you recommend that athletes do to keep themselves healthy from a cardiovascular standpoint?”

Dr. Friedman:  “On one hand, we will see folks who will come in because there’s a family history of significant cardiac disease, or a friend in their cycling or their running group or their gym had a cardiac event, and they’re concerned personally. On the other hand, athletes have a very different mentality of wanting to push through things and wanting to to just sort of get to the other end, and at all costs finish the race. And occasionally that may be okay for a knee or for an ankle, although I know our orthopedic and sports medicine colleagues may disagree on that. In the cardiovascular system, if there are things that are potentially catching an athlete’s attention, we’d rather have those evaluated sooner rather than later. Because messing around with a potential cardiac condition underlying can cause significant issues.”

Dr. Fialkow:  “Can you explain what the term ‘masters athlete’ means?”

Dr. Friedman: “A masters athlete is somebody over the age of 35 who’s engaging in competitive sport, and does so at high levels, and it’s someone to whom sport is very important and competition as well.”

Dr. Fialkow:  “So, are there particular things that masters athletes might experience that they don’t think of as a sign of cardiac conditions?”

Dr. Friedman: “Yeah, it’s subtle. And what may be not so concerning of a feature or a symptom to someone who doesn’t deal with athletes a lot may be a big red flag to someone like myself. And the range of symptoms that an athlete can experience, especially over the age of 35, can really be similar to our general cardiac population. So chest pain, discomfort, skipping heart beat, shortness of breath, fatigue. But how an athlete will experience that can sometimes be different. (They might) notice somewhat precipitously that they’re not hitting their times on their miles as much. That their power zones when they’re on the bike are decreasing. That they’re significantly fatigued. That it’s taking more energy than they would expect to complete their usual training regimen. So, all of those things are very different in how an athlete experiences it.”

Dr. Fialkow:  “Let’s address the COVID-19 experience, which is relatively new for all of us. If someone tested positive for COVID-19, what recommendations do you have, or concerns would you raise when they begin to exercise again?”

Dr. Friedman:  “Initially, as we were learning about COVID, we got a lot of data from hospitalized patients. People were showing up in the hospital with these terrible viral pneumonias, and we were finding that the cardiovascular system was impacted by that. So, we were being very conservative initially, really putting all of our athletes through a pretty significant testing in order to get them back, especially at the collegiate and professional levels.

“As those of us who were doing this at high volumes began to see lots and lots of people, we found that, fortunately, the cardiovascular implications in those who are asymptomatic, or mildly symptomatic, were quite rare. And so we we’ve adjusted our guidelines as such and we are no longer recommending cardiovascular risk stratification or testing from a cardiac standpoint to return to sport.

“The general consensus is that if you have COVID, number one, get healthy, be well, and then slowly return to sport afterward. If on your return to sport, you notice disproportionate shortness of breath, increasing fatigue, chest pain or pressure, passing out, that then warrants a further evaluation. If you’re someone who likes to engage in very intense exercise and you’ve had moderate symptoms, so when we say moderate symptoms, fevers, chest pain, difficulty breathing during the illness, or you have significant underlying medical conditions, And then you want to get back to your sport and do so at high intensities, I think risk stratification may be helpful. It may be worthwhile to go see a cardiologist at that point.  Certainly ,if someone was hospitalized with COVID and then wants to return to sport, we definitely recommend following up, and at least having a discussion before returning.

Dr. Fialkow:  “What are your recommendations to an athlete regarding supplements? And can you comment regarding anabolic steroids?”

Dr. Friedman:  “Anabolic steroids is the easy one first, in that we’re finding more and more data coming out that anabolic steroid use is linked with premature coronary artery disease, blockage in the heart’s arteries.”

Dr. Fialkow:  “If someone used anabolic steroids for a period of time, but they haven’t in several years, are they still at risk?”

Dr. Friedman:  “Yes, absolutely. The risk still exists. The risk does not go away once cessation of the drugs have happened. So yes, be aware of that.

“In terms of supplements and over-the-counter type medications, you just have to be careful with that. With our athletes, we ask about medications and what type of vitamins, minerals are you taking? Why are you taking it? What are you hoping to achieve with it? With the understanding that what you think goes into a supplement may not be there, and what you don’t think is in a supplement that may actually be there. So, it’s a really dicey game. You just have to be careful. I tend to recommend people don’t put things in their body unless they absolutely need it.”

Dr. Fialkow:  “Here’s a question from a viewer: ‘Is it imperative to do pre-participation screening before engagement in high-intensity activities and sports?’”

Dr. Friedman  “The blanket recommendation is ‘no.’ For most people out there, it is very healthy to participate in sport. The risk of something bad happening is quite low. If there are preexisting conditions, family history, things that would set off red flags, then yes, a screening would be beneficial and a discussion would be helpful.”

Dr. Fialkow: “ I know you have a special clinical interest in the usage of CPR and AEDs in youth sports. First, can you explain what AEDs are?”

Dr. Friedman:  “It stands for automated external defibrillator. They’re the red things you see in the airport or at the supermarket, that will shock people’s hearts if a dangerous rhythm is happening during cardiac arrest. All of these things we talk about — screening, controlling risk factors — what we’re trying to prevent is sudden cardiac death: a very dangerous heart rhythm that comes from the heart in a setting of stress, whether it be blockage or preexisting conditions.

“If we look at data that’s out there, 50% of youth coaches based on 2017 data were trained in CPR and AED usage, 50%. So that means if you send your kid to a league, there is a flip of a coin whether or not the coach will know how to do CPR and use any AED if something really bad happens. Totally unacceptable. It’s worse in underserved areas. We are actively working with the American Heart Association and multiple other organizations to change that. And we’re very excited about it, and I’m so grateful that Baptist Health supports the mission.”