Question for the Coaches and/or Cardiologists regarding A Fib

Triathlon Forum
1

…did a search but it came back a little scattershot. So, I’m gonna throw this specific case out there…

Got a friend, around 50 yo male, pretty fit, 6’ and maybe 200(?) lbs, found the love for cycling roughly 5 years ago.

Made gains just from riding as much as he could find time for… a couple of group rides, a couple of non group rides, per week, but not much structure.

Ready to get structured and find out what all this interval talk is about! Not looking at any real races but wants to get faster and have some pop with the group stuff. Basically, just looking to take it to the next level.

But, for the last year or so, he’s been dealing with a new diagnosis of AFib, and he’s been (per his cardiologist) tweaking his beta blocker dose to find that perfect amount that will allow him to let his HR creep up on harder efforts while still keeping him safe (knowing that the lowest doses allow the AFib to show up every now and then).

I know this is pretty common out there in the real world. How do you guys steer this kind of masters athlete that is facing this obstacle?

Curious to see what advice y’all can muster up!

Thanks in advance.

2

I work with an electrophysiologist, so I’m not a doctor. What time of Afib does he have? Chronic, persistent, or paroxysmal? How long ago was he diagnosed? Have they discussed the possibility of an ablation?

3

Those ^^^ details I don’t have. I have not heard him speak of ablation, yet. I’ll bring that up to him.

He is banging his head against a wall trying to figure out how he can use intervals to improve his cycling fitness if his HR is going to be pharmacologically ‘capped’ at a lower bpm, a bpm that may be too low to meet the demands of a, let’s just say for example, LT/95% for 8 min or that false flat where the group jumps the pace and he wants to stay on lead pack’s wheel.

So, let’s say he stays with the beta blocker approach.

With all of the reputable coaches out there dealing with SO many masters AG’ers that have started showing chinks in their aging bodies, I’m just wondering how the coach advises that guy/gal who comes to them and says: " Make me faster despite the fact that I’m HR control".

4

Not sure Arab is a age related problem.

Know a few young peps that have dealt with it.

5

Most doctors will want to try medications first. Afib is more prevalent in older people but younger people can have it as well. I would be interested in seeing if any coaches have had any experience in training someone while they are on a beta blocker.

6

Right! That ^^^. That’s what I was hoping for, also.

7

I am not a cardiologist, can only speak to my personal experiences and those I know who deal with AF. I am 37, and was diagnosed 2 years ago, after racing road/MTB at a high level for over 10 years. I have spent the last few years doing my best to learn about the diagnosis, and determine the best way for me to live the happiest, healthiest, longest life possible. This has entailed seeing many electrocardiologists, who specialize in AF, trying many medications, and venturing into the more opaque side of treatments (more below).

As noted, there are 3 types of AF, and it is important to differentiate. AF impacts all people/athletes differently, some do better with HIIT style training (multiple studies saying this helps reduce the occurrence…not for those in chronic AF, however). Food, supplements (Magnesium has been studied and shown to be nearly as effective as Propafanone/Flecanide, for some people, Taurine can help too, as well as fish oil…and many more), and exercise are all so dose dependent, and very much depend on the individual. Many people are triggered by heart rate increases, others stress, others alcohol, etc.

In my experience, there are few cardiologists here in the US who understand AF through an athletes lens, and are able to disentangle ‘you’ from the meta analysis consisting of 70 year old men, with other co-morbidities. Read Dr. Mandrola’s blog as a starting point for info, and to learn the pros/cons of ablation. If ablation is the decision, there are a few docs in the US (Dr. Hao, Dr. Natali) who should be considered. Ablation is not a long term fix for most, with a 2-10 year time horizon being the norm for most, despite with the EC will tell you.

Beta blockers are always going to keep the engine from being able to rev. There is also the question of what other meds he is on, and has he had a stress test performed while on the BB.

Yoga, sleep, stress, diet, hydration and electrolytes can also be very important and effective ways to ‘self medicate’. I have found meditation to be transformative- not just for AF, but other aspects of my life too. There is also some interesting work being done with message of the heart. Yes, this sounds crazy. Similar to massage of muscle- call it the hamstring, the idea is to address any areas of dysfunction (fascia release and better movement of the nerves around the heart). This takes a very trained hand, and someone who has the training and has worked with cadavers to know what they are doing.

Finding a coach who knows about AF, and is able to work with this athlete, holistically, not just with training might be best.

There is a book- ‘Haywire Heart’ which offers an overview (co-authored by Dr. Mandrola), although it might come across as too fear inducing for some.

Dr. Aaron Baggish at MGH in Boston has been studying athletes with AF for a long time, and has authored, or co-authored many studies on it. They also have one of the few cardiac sports labs in the US. It might be worth finding a facility/Doctor with this type experience and facility for counsel.

I work with a handful of athletes with AF, and/or eating disorders. These are 2 areas I have personally struggled (and competed), and feel I can provide the greatest benefit.

8

That’s good stuff.

Priority 1 is the health. He’s good there.

As far as trying to improve the cycling…
Right now, his best feedback that I’m aware of is, in short, drop the HR metric (will continue wearing the monitor in case the AFib kicks in), start with FTP test, do the planned wko’s using power as his focus, and watch the improvement happen. No matter what HR zones there are (pharm capped or not), the proper structure of intervals should improve his power across the board.

Makes sense to me. I’m not sure he’s sold on it cuz he’s stuck on the idea that he is ‘handicapped’ by the beta blocker.

9

Telemark gave you a very good response, I would agree with virtually all of it. I too have witnessed a lot of athletic A fib over my career, and it astounds me how ignorant most doctors are about it. To the it is just something that is broken and cannot be fixed without medications. And like a broken watch, that can be true sometimes.

But I have found that it is mostly just ignorance of the docs and the athletes that keep this going to a medication solution. Someone will come to me and ask what I think about their A-fb, and I will ask well what does your bloodwork look like when you are in a episode? I mean if you go to the hospital with this, they usually will give you a blood test, but even without, you should have at least a decade or more of your own tests, and know how to read them…The usual answer when I ask what was your mag or sodium, or potassium levels is they were normal…So I dig, what were the numbers, well I dont know, but they were normal…Here is the big problem with people and doctors, a normal mag lever could be 1.7 to 2.8 and yours was 1.7. To doctors that is normal(within range) Same goes for all the other minerals that are so critical to heart rhythms. To me a low but in the range # is just one hard workout or hot day from dipping below. It is just something people dont think about, including doctors, that riding on the low range of any of these can be very dangerous.

When I used to get my blood tests before supplementing magnesium, I would often be at that lower end. Then I had my heart episode during a race, and low and behold, I went from low range to very well into the red zone. It seems so simple and intuitive, but it is not. So I will tell you all now, get your bloodwork, keep the pages, and learn to read them. No doctor is going to know more about your health history than you, but only if you stay informed.

I love the new Quest website now, it keeps all your stats and even does graphs of which way things are going. So I can go into my yearly visit and doc says everything looks fine, but then I show him graph of something like cholesterol going up, even though it is still in normal ranges. We just cannot expect a doctor anymore to know what our last 5 year history has been, they just look at this one moment in time, and push the normal routine. It is not that hard folks, take a tiny bit of responsibility and you will be a lot healthier in the long run, and hopefully avoid any real injuries.

Go now and see if you can even access your last 5 or 10 years of blood tests, and if so, make your own graphs of all the categories. If nothing else, it is enlightening to know what is going on in your body, and should give you something to tell the doc when he says to you, “How you been doing?”

10

nothing in my blood work stood out as any different than it has been in the last 6 years when I had an afib episode in June, but I don’t think they have ever checked magnesium level, not that I can find in any test result anyway. but then, there is the idea that mine is related to my mitral valve issue and ASD.

So, for OP, hopefully your friend had all the tests needed to be sure nothing else was going on in his heart. ie echos(chest, TEE)

11

but I don’t think they have ever checked magnesium level,//

But that was kind of related to my point, you should “always” have you magnesium checked as an athlete, and especially if you are in for a heart thing. All the others I mentioned too, it is just common sense that minerals that affect heart rhythms, should be checked. So you say nothing stood out in your blood work, I would postulate that something very big stood out, the lack of any information on a critical #…

12

Tell him to go see an electrophysiologist to get ALL his real options avaliable.

13

Send him to see an electrophysiologist with experience working with endurance athletes. There are many. This thread makes it clear you don’t have all the info necessary and this needs to be addressed by an expert. And in this case, a cardiologist is not expert enough.

14

my point was 2 fold, all items checked were as they had always been, and I acknowledged Mg was not one of the items. I also was postulating other potential causes of afib, which might require and echo to find, some a bubble stress test.

since I am not planning to proceed with an ablation currently, I have time to check into other things after my OHS

15

There is also some interesting work being done with message of the heart. Yes, this sounds crazy. Similar to massage of muscle- call it the hamstring, the idea is to address any areas of dysfunction (fascia release and better movement of the nerves around the heart). This takes a very trained hand, and someone who has the training and has worked with cadavers to know what they are doing.

Seriously?? Yes, this does sound crazy and like serious snake oil salesmanship going on here.
Can you send through any links? I cannot understand how anyone can say they are massaging the heart and nerves around the heart with fascial release when it is an organ surrounded (by design) by a protective layer of bones, muscles, fat and skin. You only have to see a chest open in front of you to understand how this would appear to be complete BS by most in the know.

16

Well, this is timely. After IM Santa Rosa 70.3 3 weeks ago I had a scheduled appt. with a cardiologist just to check my heart as I am turning 50. They discovered I was an a-fib and likely was since the race. Since then I have worn a 48 hour monitor and it has not abated. So today I have an appt. with an electrophysiologist to hopefully discuss treatement. I don’t have any of the common symptoms, I only notice an extremely elevated heart rate while training. I’ll let you know what options I am presented.

17

pbnz- do you have AF?

I will let you take a look at this video, as a starting point, in regards to your question about massage and AF (and the GI connection):

https://www.youtube.com/...00ZizyYkI&t=325s

Magnesium- Be sure to slowly titrate the supplementation up. Mag can be used as a laxative and can cause more issues if starting with a big dose (some people talk about using 1G or more of mag daily). A few notes…not all Mag is the same. The bioavailability of Mag Citrate, Oxide, Malate, Glycinate, etc. all differ. They also will impact the GI in different way. Additionally, magnesium is hard to measure in blood tests, due to the fact it is not stored in the blood, so depending on when/how the measurement is taken, it can be somewhat misleading.

Advice to see an electrocardiologist is good, but be careful. You go to butcher to get meat, you go to an electrocardiologist to get an ablation. In my experience, with many EC’s, they do not want to discuss the alternatives- medication, yoga, meditation, etc. They see AF as strictly an electrical issue, which can only be addressed with an ablation. I am sure there are exceptions, but know this going into an apt. with a prospective Dr…if you are not certain an ablation is the direction you want to go, which leads to a different discussion.

18

I went into persistent afib shortly after I turned 40. Cadioversion took care of things until 45, then two ablations within the space of a year. There is some good advice here, but the deeper you dig into the issue the more it becomes evident how little is really understood about the problem. Exercise can certainly be a trigger, but so can a host of other things. And sometimes you are just screwed genetically. I found it telling that when I asked both my cardiologist and electrocardiologist about preventative measures, about the only firm statements they would make regarded alcohol. This struck a tone with me ( https://www.medpagetoday.com/cardiology/arrhythmias/61862). Granted, they may not understand much about athletes, but the science is slow to evolve as well. I would also echo the recommendations about The Haywire Heart, but after reading it I almost didn’t want to get on a bike again!!

19

I really appreciate you guys taking the time to offer up so much to think about here.

I will def share it all with my buddy.

At this moment, the hand he is dealt is the Beta Blocker route. I will encourage him to pursue all of those options, to see how deep down that rabbit hole he wants to go.

In the meantime…

and I’m picking non specific numbers…

Athlete A (my buddy not on meds) starts his next chapter of structured training.
Does FTP test. Yields an FTP of 225 w and LTHR 158 as his baseline, ground zero.
Say he finds a plan structured to improve FTP as priority 1.
Does 6 months of interval training.
Then he does an exit test and sees he has improved his FTP to, say, 236 w with a comparable LTHR.
A 5% increase in power at a HR which was similar throughout the plan.

Athlete B (my buddy on a beta blocker) does the exact same regimen.
Say his initial FTP test results in 205 w and a LTHR 140ish.

What do you think happens at the exit test of Athlete B?

While Cardiac Ouput (which, for those who are getting continuing ed for this ;), is how much the heart is pumping X how fast the heart is pumping) doesn’t determine FTP, if the demands of a hard working session can’t be met by a heart that is limited on the ‘how fast the heart is pumping’ part of the equation, then it seems that Athlete B will always be ‘less powerful’.

Even if Athlete B gets the same 5% bump in FTP, he comes to 215 w, not even touching Athlete A’s initial test because HR couldn’t meet the demands of the body once the stress ratcheted up.

Is it this straightforward?

Does this mean that he can do all the Watts Work he wants but his FTP increases will be pharmacologically limited? I’m guessing this may force him to put just as much attention to the other side of the w/kg equation. Is mastering his body comp and getting his weight ‘perfect’, eh, ideal, for a masters athlete the only way he will get faster, under these circumstances?

Or, will FTP move up whether his LTHR is 158 with lots of variability or it’s 140ish, a lower ceiling when under stess?

That ^^^ might be all I needed to ask ;)! Sorry for the rambling to get to it!

I’m just really curious as to how other wko geeks who lived on beta blockers did their thing.

You guys are great. Thanks for all the feedback coming in!

20

I went into persistent afib shortly after I turned 40. Cadioversion took care of things until 45, then two ablations within the space of a year. There is some good advice here, but the deeper you dig into the issue the more it becomes evident how little is really understood about the problem. Exercise can certainly be a trigger, but so can a host of other things. And sometimes you are just screwed genetically. I found it telling that when I asked both my cardiologist and electrocardiologist about preventative measures, about the only firm statements they would make regarded alcohol. This struck a tone with me ( https://www.medpagetoday.com/...gy/arrhythmias/61862). Granted, they may not understand much about athletes, but the science is slow to evolve as well. I would also echo the recommendations about The Haywire Heart, but after reading it I almost didn’t want to get on a bike again!!

I suffered from short-duration arrhythmias for several years starting around 60 years of age. Most commonly it would occur whilst running but also on the bike during sustained high tempo efforts. Eventually I was thoroughly checked out by a cardiologist (triathlete) and diagnosed with atrial tachycardia which is probably fairly low on the spectrum of arrhythmias. He advised me to keep doing what I was doing but to cut out the high tempo sessions.

A couple of previous posters have mentioned ‘The Haywire Heart’ which quotes “Numerous scientific studies have demonstrated the CoQ10 plays a key role in heart health, for reducing vascular disease, angina, cardiomyopathy and arrhythmias.”

After reading the book I decided to start taking coenzyme Q10, initially the 120mg pill and now the 300mg pill daily. This coincided with having to give up running after 33 years of triathlon competition. I also decided to abstain from my daily glass of red wine in the lead-up to the aquabike world champs last year. I cannot state unequivocally which step was the most beneficial but I have not had a heart spike since taking the CoQ10. And in this year’s aquabike world champs I was taken out of my comfort zone heart rate-wise during the 121km bike leg without spiking (and won my AG).