For the Sports Docs - Pulmonary embolysm(PE): Triathlon Forum: Slowtwitch Forums

For the Sports Docs - Pulmonary embolysm(PE)

Dec 8, 23 2:20

Hi all, hoping I can get some valued perspective related to a recent episode.

Background:
Age 57
RHR: 40-42
BP: 123/58
177cm (5'9)
72 kg (160lbs)
25 years in endurance sports.( 5 x Ironman, roughly 25 70.3's, plenty of single and multi-sport events annually)
Currently run about 55-70km weekly, strength training 4x20mins weekly, minimal swimming or cycling currently.
Don't drink, smoke or do any drugs, eat a very healthy diet, sleep 7-9 hours nightly.
I currently only race 10-21km running events, recently more 10km's as looking to build speed back up. I am pausing tri's until I hit 60-64 AG.
Reasonably competitive runner, usually top 5-10 in 50-59 AG out of 100-200.

Medical background:
Was diagnosed with chronic ulcerative colitis 08/2008.
Pulmonary embolysm during flare-up, likely caused by long distance flight 08/2012
Total Colectomy; 04/2013 > 04/2014
Current health related to previous condition, excellent. Take no medication whatsoever or have any negative effects from total colectomy.

Pulmonary embolysm(PE):
I was diagnosed with a pneumonia in my right lung mid September after feeling like I had been hit in the right back kidney by a golf club (referral pain apparently).
I immediately saw a lung specialist, got X-Ray'd and ceased all forms of training,rested and commenced a course of antibiotics and painkillers as the pain was quite substantial at times.
4 weeks later, literally one day after I left the specialists office and chest X-Ray confirmed that the majority of fluid that I had previously had (+- 150 millilitres had drained), I started to feel the same lower back pain on my left side now, which became exceptionally painful so much so that I took a painkiller and went to the hospital where I immediately had a CT-Scan and was shortly after admitted for 2 nights with a Pulmonary Embolysm.
I was vaccinated twice daily with anticoagulants.

Fast forward until yesterday.
Still on Xarelto 20mgs daily (anticoagulant), zero pain and have been walking 10km daily for the past 5 weeks and for the past 3 weeks doing light strength(Dips, Hanging leg raises) and mobility training.
I was given the green light to commence running again, 3-5 km per session in Z2 which I have now done for the past 2 days.

My query:
I was advised by my lung specialist that because this has been my 2nd PE, the first as mentioned was whilst very ill with Ulcerative Colitis and likely triggered on a flight from Canada to Singapore, that I will need be on anti-coagulant (Xarelto) for 6 months from date of diagnosis, so another 4 months.
She also advised that I am prone to Pulmonary embolysm's as my blood protein in the hematology report indicates. This could be genetic or because of the total colectomy, 'I believe' this was the reasoning.
I am unsure if I can resume training as an experienced endurance athlete, incorporating periodisation, and a structured training plan including track and Z4 and Z5 sessions without causing a PE and/or a potential stroke or heart attack during training or an anaerobic event.

Thank you for reading and any potential helpful qualified advice.

Terry

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

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Re: For the Sports Docs - Pulmonary embolysm(PE) [canuck8] [ In reply to ]

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dcpinsonn

Dec 8, 23 5:01

Post #2 of 12 (758 views)

There have been some good threads on here on PEs -- I would recommend going back & doing a search for them. I'm not a doctor but had a PE in 2017 & got back to training at a decently high level after that (BQ running, 70.3 Worlds qualifier). I didn't know at the time that I had Factor 5 so I'm on blood thinners for life. I just try to be more careful on the bike & do most of that training indoors -- it's not worth it to have someone hit me & bleed out because of the medication I have to take. It sounds like you developed one clot from the flight & that genetics might be at play for the second. I would try to confirm what caused the second. Every situation is different but I don't see why you can't get back into training at a high level now that the clot has dissipated & now that you're on medication. I don't see how training would cause another PE. Again, I would listen to your doctors. Unfortunately, there isn't a ton of good literature out there on training post PE/on blood thinners. The majority of people who develop clots are sedentary. But athletes come into the equation after pushing themselves at races (maybe being dehydrated) & then hopping on a plane to travel home.

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Re: For the Sports Docs - Pulmonary embolysm(PE) [canuck8] [ In reply to ]

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jaretj

Dec 8, 23 11:33

Post #3 of 12 (681 views)

The 6 months on Xaralto this is because the drug company only did 6 month tests and nothing shorter. (As explained by my doctor)

After my PE in 2018 I went back to regular training within 6 weeks. I did stay on Xaralto for 6 months but took a week break when I went to a training camp 3 months in. I was concerned that if I fell off my bike I'd bleed out

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Re: For the Sports Docs - Pulmonary embolysm(PE) [canuck8] [ In reply to ]

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WannaB

Dec 8, 23 12:20

Post #4 of 12 (658 views)

As a Pulmonologist, and then co-director of my Health System's PE response team, this is something I deal with frequently. I am going to give some very general advice, and ask that you stay in close contact with your Medicine team for specific guidance.

Pulmonary Embolism is a big deal with many implications. It can also be frustrating to manage due to numerous factors, as there isn't always a perfect black and white answer. Risks for, and consequence of can be variable, and treatment often ends up being individualized with shared decision making with patient.

In very general terms, need to first identify risk of why this occurred. Having more than one event in a lifetime increases the need for vigilance. Because at the end of the day a large PE is life threatening. And each event statistically increases risk to have another. Why this is important is it factors into duration of therapy. At absolute minimum we treat for three months. In selected populations we treat for 6 or even 12 (based on recurrence, severity of event or evidence of chronic clot burden). And in anyone deemed to be persistent risk, we consider lifelong therapy. Again, this decision is also shared with patient as there is not a perfect answer and patient lifestyle or fear/anxiety factor in.

Your prior event related to Ulcerative Colitis (inflammatory bowel disease a risk in and of itself) combined with air travel argues for a provoked event. So once you modify those risk factors, reasonable to discontinue therapy. Recurrent event requires search for what incited it. If you indeed have "blood proteins in Hematology report", that is concerning. This would require much more thought and discussion with your team and specialists.

As far as training. I have taken care of many active/high performance people with clots. I have not had major endurance athletes who red line it the way we do. But there are a few things that work as general principle. Bleeding risk is obvious. Want to avoid any and all head trauma. Cardiovascular fitness should recover as you are already noting. Small to medium size clots typically resolve within ~ 6-8 weeks. There can be some local inflammation/injury to lung tissue as a result of clot, that should heal as well. So from a Pulmonary standpoint, you really shouldn't loose much lung capacity. The concern is from a cardiac standpoint. Blood clots put secondary stress on the heart (the right side). You can develop acute, and in a worst case scenario, more chronic pulmonary hypertension. That is not the case for most people. But that would be where your exercise limits will likely be felt.

Monitoring HR, O2 saturations, and symptoms have to be your guide. I would advise you keeping your Medicine team informed if an when you plan to ramp up intensity, as they are the ones that know you, and would want them to be the ones to support your regimen. But overall, I feel pretty good for your ability to resume level of fitness.

Last edited by: WannaB: Dec 8, 23 18:44

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Re: For the Sports Docs - Pulmonary embolysm(PE) [dcpinsonn] [ In reply to ]

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canuck8

Dec 8, 23 20:30

Post #5 of 12 (578 views)

Thank you for detailing your experience DC.

I did look at a few and thx for highlighting that. I had looked at a few, but as I probably never explained clearly, I am worried about what is the cause of me getting PE, in addition to the blood protein. Although the lung specialist stated that it is caused by my 'blood protein metrics' I really want to find out what is triggering it.
I have done some basic research which does NOT compare to personal interaction with a sports doc, lung specialist, hematologist or other specialist that can advise properly and accurately, hence my post here. That said, my research did research the obvious, but also factors such as my previous UC, dehydration during training or racing, as outliers that I thought 'may' have contributed.
I have a 2 high ranking IM AG's as friends who are on blood thinners permanently after having a stent, not from PE though, so the only commonality is the medication in my understanding.
My lung specialist stated that at this stage it is not determined that I need to be on anticoagulants for longer than the 6 months from diagnosis though.

"But athletes come into the equation after pushing themselves at races (maybe being dehydrated) & then hopping on a plane to travel home." This I am aware of but is certainly not my case. I have previously raced numerous IM's far from my home (Penticton, Kona, Busselton) and flown home with no problems.

Thanks very much again for the response and your insight.

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

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Re: For the Sports Docs - Pulmonary embolysm(PE) [WannaB] [ In reply to ]

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Darren325

Dec 8, 23 20:31

Post #6 of 12 (577 views)

WannaB wrote:

Thank you for this!

I had a PE ten years ago at 39 years of age after several Asia/North America flights.
Something up with my protein S and higher risk of getting another.
I was on warfarin forever and last two years switched to Xarelto.

Aside from the obvious bleeding risks, is there any information you are aware of that discusses long term impacts of taking Xarelto. This has been an ongoing risk analysis conversation with my physician (who I believe is excellent) and I am always looking to be better informed in this decision to continue the therapy.

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Re: For the Sports Docs - Pulmonary embolysm(PE) [jaretj] [ In reply to ]

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canuck8

Dec 8, 23 20:34

Post #7 of 12 (576 views)

jaretj wrote:

Thx Jaret.
So in my understanding, you had a blood clot, as did I recently as highlighted and you commenced regular training (swim,bike,run IM volume) 6 weeks later whilst on Xarelto ?
Was this your first and only PE ?
Were you able to accurately determine with your medical team how or why you developed a PE ?
Thx v m.

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

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Re: For the Sports Docs - Pulmonary embolysm(PE) [Darren325] [ In reply to ]

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WannaB

Dec 8, 23 21:39

Post #8 of 12 (563 views)

Darren325 wrote:

Aside from the obvious bleeding risks, is there any information you are aware of that discusses long term impacts of taking Xarelto. This has been an ongoing risk analysis conversation with my physician (who I believe is excellent) and I am always looking to be better informed in this decision to continue the therapy.

So, when indicated, benefit far outweighs any risks or concerns. The Direct Oral Anticoagulants (DOAC) such as Xarelto have been around since 2010. So while our experience is still young, we have been pretty pleased with their safety and effectiveness. The biggest thing we looks for is to ensure someone doesn't have renal or liver dysfunction as that can affect clearance, and then drug interactions. Basically, anything that can increase potency and bleeding risk.

Putting someone on lifelong anticoagulation is obviously a huge decision, and not taken lightly. When that is ultimately best decision, I have some comfort based on the other major reason people are on DOACs. Stroke prevention due to Atrial Fibrillation is an indication for indefinite/long-term anticoagulation, and there are many many people on long-term therapy as a result. They do well, and as far as I know, there isn't any major concern due to long-term usage in these first 10+ years that we have been using them.

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Re: For the Sports Docs - Pulmonary embolysm(PE) [WannaB] [ In reply to ]

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canuck8

Dec 8, 23 21:52

Post #9 of 12 (547 views)

WannaB wrote:

WannaB, thank you very much for your professional opinion and advice regarding the complexity of managing PE, individualized treatment approaches, and the importance of collaboration with my healthcare team for a safe and effective recovery.

Noting your numerous points, and that a PE event includes numerous factors and implications that are unique to the individual, and hence a bespoke treatment therapy based upon these factors and lifestyle risks is required.

As this is my 2nd PE, although I am certain the 1st was due to long-distance plane travel in a anemic state, my understanding is that I need to action the following;

Identify the risk factors that led to this specific event and determine exactly what the Hematology report stated, including what 'negative' blood protein metrics that I possess that increase the chances of a future PE.
Continually monitor blood oxygen (at least daily) in addition to heart rate training metrics to highlight potential 'silent' symptoms that may indicate pulmonary hypertension, cardiac stress or other.

My lung specialist indicated that I do have have minor scarring on left lung from pneumonia bout, but both of my lungs are functionally undamaged.
I am unsure how, and to what extent, exercise may be limited from a cardiac perspective on the right side of the heart as well.
I do not understand the comment "Modify risk factors, related to prior UC, may support discontinuation of therapy". if youy don't mind expanding on this please.

Thank you very much again for your advice and thoughts here.

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

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Re: For the Sports Docs - Pulmonary embolysm(PE) [Darren325] [ In reply to ]

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canuck8

Dec 8, 23 21:56

Post #10 of 12 (544 views)

Darren325 wrote:

WannaB wrote:

Darren how has this affected your training please ?
I 'may' have the same protein problem, but I will confirm when AI see specialist again.

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

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Re: For the Sports Docs - Pulmonary embolysm(PE) [canuck8] [ In reply to ]

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WannaB

Dec 8, 23 22:32

Post #11 of 12 (529 views)

canuck8 wrote:

As this is my 2nd PE, although I am certain the 1st was due to long-distance plane travel in a anemic state, my understanding is that I need to action the following;

Identify the risk factors that led to this specific event and determine exactly what the Hematology report stated, including what 'negative' blood protein metrics that I possess that increase the chances of a future PE.
Continually monitor blood oxygen (at least daily) in addition to heart rate training metrics to highlight potential 'silent' symptoms that may indicate pulmonary hypertension, cardiac stress or other.

I will answer second part, first. Sorry if I made it convoluted. Your first event is what we could consider provoked, meaning they identified the risks. Ulcerative Colitis/Inflammatory Bowel Disease is considered an increased risk for blood clots, compared to people who do not have it. The thought is the complex inflammation and auto-immune process that causes this, can induce a more hypercoaguable state. This does not mean everyone who has UC will have one, but based on what is going on in the body, they are more primed/at risk in the perfect storm. Add in long air travel, which is a known risk to cause blood clots, and we can explain why you developed it. So after completing treatment, we are comfortable stopping therapy as we think we know why it occurred. After colectomy, down regulating the inflammation and "modifying" risk state, reasonable at that point to not commit you to lifelong therapy. Same for anyone who randomly develops a blood clot after long car or air travel. We know that prolonged immobility and venous stasis can cause clot. So once we treat from that event, we are comfortable stopping with counseling about how to try and avoid (ambulation and frequent stops on trips, maybe compression stockings, etc).

The second event is concerning, as it suggests your body still persists with ability to have a more hypercoaguable state. There are numerous possibilities, to include certain genetic and, or acquired blood disorders that make you chronically at risk. That is what I wonder about your bloodwork.

Back to the main question of the thread! Your exercise tolerance and endurance. The acute stress on your body early on is from the clot, the vascular inflammation, the local lung injury, and then the secondary effects as your right heart has to pump blood into and through the lungs to pick up oxygen and deliver it to your left heart. In the setting of clot, the right heart has to work harder to pump the blood forward (so to speak). The lung recovers pretty well. The vascular inflammation and then right heart strength has to recover and rebuild. That is often what can cause your HR to be elevated with activity and your oxygen to trend lower. That should ultimately recover as well, it just lags a bit.

As other have noted, and I have seen with my patients, increasing activity and HR should not be a problem. And short of having a massive spike in blood pressure, vigorous exercise even on anticoagulation is generally fine. Your HR and O2 sats will help guide you on how and when your body is recovering to the point to move to the next zone.

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Re: For the Sports Docs - Pulmonary embolysm(PE) [WannaB] [ In reply to ]

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canuck8

Dec 8, 23 23:38

Post #12 of 12 (505 views)

WannaB........I understand completely and am truly thankful for your input and advice here.

However the lung specialist did state that the hematology report concluded that the cause was a blood protein marker, that could be genetic OR related to previous UC. I state previous as I have had ZERO issues since the colon was removed.

Thinking back over the past year, I have done a few things differently that I hope may be 'behavioral' changes that "may" have contributed to the PE as opposed to blood protein, although from my uneducated perspective;

- I have not raced any anaerobic events since before I had a total colectomy(2013/14), I started racing 10km stand alone running events this past year where I really push it, specifically in the final 3km's hitting Z5 and basically going at 95% of my max HR for the final 1.5 - 2.0 km. In training I have been doing hard 400's, but only as 5% of my overall run volume of which 85% is at Z2.

- I live in a city where a car is unnecessary as public transportation is extremely close, cheap and comfortable. I bought a new and very comfortable SUV one year ago and besides driving 3-4 hours (often uninterrupted) to many races and driving back the afternoon of the morning ace, or the following day. Additionally, I drive the same duration every 3-4 weeks for weekend get aways.

Perhaps not coincidentally, the discomfort that was diagnosed as a PE the following day, happened on one of these trips and symptoms started at the end of a 3-4 hour drive.

Thank you very much again !

"You are never too old to set another goal or to dream a new dream" - Les Brown
"Discipline is the bridge between goals and accomplishment" - Jim Rohn

Last edited by: canuck8: Dec 8, 23 23:58

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