Monday, October 30, 2017

Running and Your Heart, Part V: Coronary Calcifications


So I thought I was done with the Running and Your Heart series, but some questions came up that made me realize I needed to clarify a couple of points.  And I don't know, maybe we're not done with the series; I could see doing some more in-depth posts in the future about some specific issues.  A detailed post on atrial fibrillation might be in order.  For now, though, we're going to delve a bit deeper into coronary calcifications, their significance, and what the research means for us as distance runners. 
image: the Heart Research Institute

As such, think of this post less as the fifth installment in the series and more as part IIIb, as we'll be addressing basically what we talked about in part III (and touched on briefly in part IV).  Let's recap some of the main points from that post.  The coronary arteries are blood vessels that carry blood to the heart muscle, supplying that muscle with the oxygen needed to carry out its function--namely, pumping blood throughout the body.  Blood flow through these blood vessels can be compromised by a disease process called arteriosclerosis--literally, a hardening of the arteries.  Generally, arteriosclerosis is caused by the accumulation of plaques within the walls of the arteries, resulting in a narrowing/hardening of the arteries (stenosis) that can impede the flow of blood to the heart muscle.  In times of increased stress on the heart (i.e., exercise), the demands of the heart muscle for oxygen are increased; if not enough blood is able to flow through these narrow, stenotic arteries to meet this demand, the heart muscle suffers from ischemia (lack of oxygen).  Prolonged ischemia, or complete occlusion of the artery, can lead to infarction, or death of a part of the heart muscle--which, if significant enough, can be debilitating or fatal.

Remember that in part III, we discussed the use of CT scans in detecting underlying coronary artery disease--namely, looking for calcium deposition in the coronary arteries.  Calcium is a component many arterial plaques and is easily visible on high-resolution CT scans.  This test especially useful in folks who don't have any symptoms of coronary disease but may have risk factors.  A growing body of research indicates that long-term endurance athletes--those who have been training at high levels or volumes for a decade or more--paradoxically have higher rates of coronary calcification than those of their age-matched peers in the general population, despite having much lower rates of many risk factors, like diabetes, hypertension, or obesity.  Remember that these studies have demonstrated correlation, not causation--we can't say that sustained exercise is the cause of this finding, only note that the relationship exists.  And recall also that we've yet to demonstrate what the real-world implications of these findings are--which is the point of this more involved discussion. To wit, the question: does having more coronary calcification lead to a higher risk of having a cardiac event?  The short answer is, yes--but for marathon runners, maybe not.

Numerous studies of the general population (that is to say, not specifically among marathon/ultramarathon runners) have correlated coronary artery calcification (CAC) scores to a higher risk of suffering a cardiac event, such as heart attack, death, or the need for revascularization (a re-opening of a blocked artery).  The exact degree of risk varies by study, but ranges from a four-fold risk increase to a twenty-fold increase have been reported in studies of varying size and quality.  Higher CAC scores are associated with a higher degree of risk, with significant risk increases generally seen with scores above 100 or 300 (zero is "normal").

OK, so that's bad.  Higher scores are associated with higher risk, and we've demonstrated that "obsessive" runners have higher scores, on average, than the general population.  That means our risk of suffering a significant cardiac event must be much higher, right?  Well, not necessarily.  First off, as I mentioned in the earlier post, there is research suggesting that long-term aerobic exercise leads to coronary arteries that have larger diameter, and have a greater ability to dilate.  (The autopsy of seven-time Boston Marathon champion Clarence DeMar famously revealed that his coronary arteries were two to three times wider than average.)  Secondly, to better understand our level of risk, we need to understand the nature of arterial plaque and the reasons one might suffer from a cardiac event.

Generally, narrowing of the coronary arteries, in and of itself, is unlikely to cause a cardiac event.  The precipitating factor in a cardiac event is often the rupture of an arterial plaque.  A piece of the plaque can break off and get carried "downstream" to a narrower part of the artery.  If it gets lodged there, it can cause a complete occlusion of blood flow to an area of the heart muscle, resulting in a heart attack.  So if we can identify which plaques are more susceptible to rupture, this will allow for a better stratification of risk.

Simply put, not all plaque is created equal.  Arterial plaque is generally composed of various substances: fat, cholesterol, calcium, and fibrin, to name a few.  One way of thinking of plaques is to classify them as either "hard" or "soft".  Hard plaque, made up of predominantly calcium, is generally considered more stable and less prone to rupture than softer (mostly cholesterol) or "mixed" plaque.  The good news is that while high-volume exercisers have higher CAC scores, they are much more likely to have hard, calcific plaques (read: stable) and much less likely to have mixed plaques than subjects who exercised the least.

So while we know that elevated CAC scores in the general population put people at risk for cardiac events, the risk for runners who have elevated CAC scores may not be the same, because of the composition of their plaques, and possibly the dilation of their coronary arteries.  Perhaps this is why, despite the fact that runners appear to have paradoxically higher-than-expected rates of calcification, cardiac events among habitual marathoners seem to remain relatively infrequent occurrences. 

Thursday, October 26, 2017

Race Report: WC 50--There's No Cure for Stupid


This fall has been less about racing per se and more about setting myself up for 2018, when I have three big (for me) races on the calendar, plus hopefully an attempt at the Bob Graham Round (fingers crossed that trip comes together).  But racing can be part of training as well.  Races are good opportunities to experience stimuli that you might not be getting in your weekly training, either in terms of distance or intensity, and they can be a nice gauge of fitness as you shape your plans and goals moving forward.  My experience in September at Mountain Madness fell into the former category.  I travelled to North Carolina two weeks ago for the latter.

My sister and her family have lived in Charlotte for about 12 years now, only about 20 miles from the US National Whitewater Center, which is a really cool facility for aspiring elite kayakers and rafters.  Since opening in 2006, the center has grown to include rock climbing, zip lines, high ropes courses, and many miles of mountain biking trails, and they now host all sorts of events and races.  The WC 50, now in its fifth year, is the ultramarathon entry into the Whitewater Race Series, and a race I've wanted to run for some time due to its proximity to family.  The dates worked this year for a quick trip down for my nephew's birthday party and an early-morning jaunt in the trails.  I expected a low-key day out; I had no idea of the competition, but looking at previous results, I planned on running a relaxed effort near the front and seeing where my fitness level would get me.

We started in the dark, at 6am, on a fairly warm morning--temps were already nearing 70 degrees.  The race started out with a short "parade loop" around the whitewater course before heading into the trails for the first of three 10.2-mile loops.  I set off at a relaxed but quick tempo and was immediately at the front of a field of about 100.  By the time we hopped onto the singletrack about five minutes in, I was out in front with one other runner and it looked like we'd be on our own most of the day.  We ran together at a nice pace; the miles were marked with signs tacked to the trees, and we were clicking off splits in the 7:40/mile range on some fairly technical but runnable mountain bike trails.  It was a bit tough monitoring our footing with just headlamps, but it was fun running at speed through the darkness, and the early miles passed by quickly.  We ran together throughout the first lap.  The second half of the loop had a few significant climbs, though we kept up a solid tempo.  The mile splits suddenly had jumped up to over 10-12 minutes per mile, but I think this was due to incorrect markings as opposed to any change in our effort or actual pace.  (This sense was supported by subsequent laps, when we would again run 7:30-7:40 pace on the early "miles", followed by 10-12 minute "miles" later on.)  Regardless, we rolled through the first 11+ mile lap in about 1:39; I grabbed my Orange Mud handheld and ran on through the start/finish aid station, while my companion--a strong local runner named Chase Eckard--took a quick break with his crew before catching back up within the first mile of lap 2.

We kept the effort steady and chatted through the early part of the lap.  Chase said, "When do you think Karl will catch us?"  I knew that Karl Meltzer, the winningest 100-mile runner of all time, had been in town for the pre-race dinner, promoting Made to Be Broken, a film about his record-breaking run on the Appalachian Trail.  I hadn't realized he was racing, although I had considered the possibility.  For some reason I had assumed that if he was racing, it would be in the 50-mile, which had started at 5am on a course that incorporated our entire 10-mile loop plus an additional 7 miles on each of three 17-mile loops.  

"Oh, is Karl racing?" I asked.  

"Yeah," said Chase, "he started off at the back."

I have no idea why--partly because of my pre-race assumption, I guess, and partly because we were leading the race and why would I be leading a race against Karl Meltzer?--Chase's comment simply reinforced my notion that he was in the 50-mile.  I wasn't sure if he would run the opening 17 miles of his race in under 2:40 on this course, so by my twisted logic I wasn't clear if we were actually ahead of him or not at this point.  "Well," I said, "if we finished our first lap before he did, we might be ok; he might catch us later in this lap.  But either way, we'll pass him when he does the extra seven miles on lap two."  Chase didn't really have much to say about that, which given that Karl was actually in our race makes perfect sense; in retrospect I must have sounded like a freaking moron.

ANYWAY, we ran together until about the 16-mile mark, when Chase blasted away on a long downhill stretch and I eased off a bit, resisting the urge to really open up this early in the race.  Instead I took in some calories, slamming down two GUs in rapid succession (my first calories to that point, I realized, even with the fat adaptation I've got to be a little smarter about that) and settling into a nice solo rhythm.  I caught a few glimpses of Chase on some longer stretches, about a minute ahead at a couple of spots, before we started in on the climbing again.  I didn't expect to start racing for a few miles yet, but suddenly he appeared in front of me near the 20-mile mark, walking at the top of a long but runnable uphill.  We exchanged a few words of encouragement as I made an easy pass.  By the time we reached the end of lap 2, a little over a mile later, I already had about two minutes on him, and I was feeling good.  Barring disaster, I felt like I had it in the bag.

Disaster is exactly what happened about 25 minutes later.  I rolled through the opening miles of the final lap feeling a little tired but generally relaxed and strong.  My splits were within shouting distance of my first two laps.  I passed the 4-mile mark of lap 3, about 25 miles overall, in 3:52; doing some quick calculations (and taking into account the longer "miles" in the second half of the lap), I was looking at about a 4:55, maybe right around 5 hours if I slowed down a little.  I briefly stepped off the trail to fertilize the soil, not realizing I was near one of the myriad switchbacks on the course.  Somehow I got turned around and ended up on the wrong end of the switchback.  After a couple of minutes of running, I started getting a sinking feeling in my stomach.  The trails all looked the same, but some of those turns were looking too familiar...as if I had just run them...and then I came around a corner and arrived back at the one-mile mark.

Well, that was just too much.  I sat down on a log by the side of the trail and had myself a little pity party; after a couple of minutes I started walking backwards towards the start, ready to throw in the towel rather than run another nine miles.  After a few minutes of that, though, I felt pretty stupid, having travelled all the way down and then not even bothering to finish; I thought about Jim at States last year, sighed, turned around, and trudged back over the same three miles I had just run.  I finally cruised into the mid-loop aid station about 40 minutes behind schedule.  The volunteers were all very confused--none of the leaders had actually gone past me--but after I explained what happened they were sympathetic, as they had seen Chase and I up front all day.  The told me Chase was now running second to Karl, which is how I came to finally realize that Karl had been in the 50K all along; they poured me a shot of bourbon, which at this point I figured what the hell, and sent me on my way.

Speedgoat Karl on his way to the win.
photo: US National Whitewater Center
I actually felt pretty good the rest of the way, and managed to pick off one or two other folks en route to finishing in 5:41, officially 6th but in actuality 5th (looking at the splits, the 5th place runner is credited with a second lap of 1:21--fifteen minutes faster than anyone in the race ran any other lap on the day, and almost 30 minutes faster than either his first or last lap, so there's no way that's legit, but whatever).  I felt fine afterwards, and actually wasn't even all that sore the next day, so it confirmed at least a decent level of fitness.  And for the first hour or two I didn't even care about what had happened; I basically shrugged afterwards talking to Karl and said "That's trail racing, shit happens."  But after a little while the disappointment really set in.  I had put over seven minutes on Karl after one lap; on lap two I had given back barely 30 seconds.  I had basically tossed away probably my only chance to beat a legend like Karl--and not some outside chance; the race was basically over--by being a fucking idiot.  

Name
Lap 1
Lap 2
Lap 3
Finish
Karl Meltzer
1:46:24
1:36:51
1:45:31
5:08:47
Bill Shires
1:49:18
1:38:57
1:51:36
5:19:51
Chase Eckard
1:38:55
1:39:11
2:04:08
5:22:15
Paul Halaburda
1:48:07
1:48:39
1:55:29
5:32:16
Stephen Spada
1:49:17
1:21:36
2:27:01
5:37:55
Jason Friedman
1:38:57
1:37:24
2:25:31
5:41:52

In retrospect it was the perfect commentary on my ultra season for 2017.  I did fine, winning a couple of small races that I fully expected to win; I came into every big race (Rocky Raccoon, Cayuga Trails) in great shape and then had great performances sidetracked by weird shit happening.  Only difference was this time I brought the weird shit on myself.  A fitting ending to a frustrating year.  Fuck.

Twelve weeks to Bandera.

Monday, October 9, 2017

Running and Your Heart, Part IV: Running and Mortality

photo: mpora.com

At long last, here is the final post in the "Running and Your Heart" series.  When we started I thought I'd finish this series in about 4-6 weeks.  Now it looks like we're pushing past 6 months.  Hopefully it will have been worth the wait.

So over the past several months we've (rather infrequently) investigated the relationship between long-term endurance exercise and the heart.  We've discussed normal heart function, cardiac adaptations to exercise, abnormalities that can arise from these adaptations, and the impact of marathon and ultramarathon running on coronary artery disease.  (As a brief aside, one of the theories that I discussed in the last post--that the increased coronary calcification seen in marathon runners is quite possibly hard, stable plaque that is less likely to rupture and cause actual problems--has since been supported by some recent studies.  Alex Hutchinson, whose work is generally spot-on, has a good summary of these articles in Runners' World.)  What I've tried to stress is that we should not be alarmist about these issues, but that we should not be naive either in thinking that our running makes us immune from heart disease.  Rather, we need to be aware of the potential problems that can arise from long-term training and be able to address these possibilities with our physicians in a responsible way.

OK, that's all well and good.  But when we start seeing articles with titles like "Fast Running is as Deadly as Sitting on the Couch, Scientists Find" and "Excessive Running Could Kill You", it's natural to feel a bit concerned.  We know running, on the whole, is good for us.  Since Jim Fixx gave us his seminal work The Complete Book of Running in 1977, detailing how running saved him from what seemed to be his genetically destined early cardiac death, we've taken it on faith that diligent training leads to longer lifespans.  But with all the studies in the past decade that have been hinting at correlations between long-term marathon running and paradoxical heart disease, is it possible that we're taking things too far?  Have we reached the point where all this running is actually shortening our lifespans?  (And wait a second, didn't Jim Fixx die pretty young after all?)

Much of the recent concern over the possibility that too much running might actually be bad for you centers on a couple of ideas.  One is the relationship between long-term marathon running and coronary artery disease, which we discussed in detail last time.  Just to sum up where I stand on this: I think it's pretty unambiguous that people who train vigorously for marathon-and-longer distance events for many years do have a higher incidence of coronary artery calcification than those who do not, and that the cardio-protective benefits of regular aerobic exercise require much less mileage and less intensity than many of us (including myself) are actually doing.  However, as I pointed out in the links above, not all coronary calcification is created equal; while you'd certainly prefer less calcification than more, and no calcification to any, the calcific plaques demonstrated in asymptomatic long-term runners are not the same in terms of composition (and possibly long-term risk) as those we'd associate with smoking, uncontrolled hypertension, diabetes, or other native disease states.  Even if we assumed that we may be at higher risk of suffering a serious cardiac-related event as a result of strenuous running (by no means a reliable assumption), I don't think the data support the conclusion that this risk outweighs the mortality benefit of the decreased incidence of high blood pressure, diabetes, and cancer that runners consistently demonstrate over their more sedentary peers.

The other idea that has received a lot of publicity in recent years is the so-called "U-shaped mortality distribution."  This concept is based largely on the work of James O'Keefe and other researchers involved in the Copenhagen City Heart Study, as well as Duck-chul Lee, who in 2012 presented a rather controversial abstract at the American College of Sports Medicine conference.  According to their research, when plotting mortality (the dependent variable) on the y-axis against mileage (the independent variable) on the x-axis, the data shows the highest mortality values at the lowest and highest ends of the exercise spectrum (i.e., a "U-shaped" distribution):

The "U-shaped" mortality curve.
figure: American College of Cardiology 

In other words, those runners logging much less mileage--as little as a mile a day in some cases, and certainly less than 20 miles a week--saw the greatest benefit in mortality, while those running more mileage saw little to no mortality benefit at all!

These are the studies that have prompted most of the terrifying headlines you've read in recent years, and these are the studies I want to talk about today.  Not to argue with their data, but to try to help us understand why some of the authors'--and the media's--conclusions are not necessarily as dire as we've been led to believe.

Lee et. al. demonstrated a 20% reduced risk of mortality for runners vs. non-runners over a 15-year follow-up period--great news!  However, the study appeared to show that runners averaging more than 20 miles per week had not only higher rates of mortality than those running less, but that their mortality rates approached those of sedentary, non-running peers.  However, these findings were based on the researchers' adjustments for various conditions, including body mass index (BMI), smoking, diabetes, and hypertension.  What does this mean?  When comparing different groups of people, researchers can run into a problem with what are called confounding variables.  These are differences between groups that might affect what you're trying to measure.  In this case, the researchers were trying to determine the relationship between running mileage and mortality.  Of course, there are many different variables that contribute to one's mortality risk, and without accounting for these variables, it's difficult to ascertain whether differences between groups of data is due to what you're actually trying to measure (running mileage) or to something else that you're not measuring.  So the researchers performed what's called statistical correction to take these variables into account.  Simply put, they eliminated the effect of as many of these confounding variables as possible, trying to answer the question: "If all other things are equal--if all of these groups are made to be the same in terms of their rates of obesity, diabetes, blood pressure, etc.--then what effect does mileage run have on their mortality risk?"

Let's be clear: there's nothing underhanded about this.  Statistical correction is a perfectly legitimate (and in most cases necessary) part of scientific research; it's how we attempt to discern cause and effect in situations with many different variables in play.  In this particular case, however, we run into a problem.  The reason that running might have a benefit on mortality is that it makes you healthier overall.  That is to say, vigorous runners are less likely to be obese, to have high blood pressure, or to suffer from diabetes.  If you eliminate these benefits as "confounding variables," it only stands to reason that the mortality benefits of running disappear from the data as well.  The problem with this study wasn't that the authors tried to correct for confounders; it was their classification of the benefits of exercise as confounding variables in the first place.  Alex Hutchinson was all over this pretty much right away, and in 2013, cardiologist Thomas Weber pointed out the problem in the journal Heart:

"One possible explanation for the U-shaped curve...is that the authors adjust for body mass index, hypertension and hypercholesterolaemia. Running has been shown to lower those risk factors in a dose-dependent fashion with no sign of negative returns until at least 50 miles/week. Arguably, adjusting for all these factors is akin to adjusting for low-density lipoprotein (LDL) values in a study analysing the survival benefit of taking statins to treat hypercholesterolaemia. Put simply, this editorial represents a selective interpretation of the available data, at the best."

What Weber is saying is, if you were studying the impact of a drug for cholesterol on mortality, and you had two groups (one which took the drug and one which didn't), it wouldn't make any sense not to look at the differences in the cholesterol levels between these two groups--how else would you expect the drug to improve mortality if not by impacting cholesterol levels?  Similarly, if we grant that running makes us healthier because it protects against hypertension, diabetes, and obesity, then those are very likely the reasons it would have a mortality benefit; removing those effects from the analysis doesn't make sense.

Indeed, when the final paper of this study was published in 2014, the researchers eliminated the statistical correction--and the U-shaped mortality curve seemed to vanish!  Instead, the authors, now concluded,

"[R]unners across all 5 quintiles of weekly running time, even the lowest quintile of <51 minutes per week had lower risks of all-cause and CVD (ed: cardiovascular disease) mortality compared with non-runners. However, these mortality benefits were similar between lower and higher doses of weekly running time. In fact, among runners (after excluding non-runners in the analyses), there were no significant differences in hazard ratios of all-cause and CVD mortality across quintiles of weekly running time (all p-values >0.10)."

That is to say, running even a little bit lowered mortality risk, and this lower risk appeared constant regardless of the time or distance run per week. Perhaps not surprisingly, this received significantly less media attention than the earlier version of the results.

Similarly, the researchers in the Copenhagen City Heart Study reported findings that seemed to support the U-shaped mortality curve, concluding:

"We found a U-shaped association between jogging and mortality. The lowest mortality was among light joggers in relation to pace, quantity, and frequency of jogging. Moderate joggers had a significantly higher mortality rate compared with light joggers, but it was still lower than that of sedentary nonjoggers, whereas strenuous joggers had a mortality rate that was not statistically different from that of sedentary non joggers." 

and cited Lee's paper in their discussion of the results.  Again, however, these conclusions don't tell the whole story.  While this study followed nearly 1100 runners over a 12-year period, only 40 of these runners qualified as "strenuous joggers" according to the rubric of the study (running at a pace of 9:00/mile or less for at least 2.5 hours/week), and there were only two deaths among this group during the course of the follow-up period--not nearly enough of a rate to draw any meaningful conclusions.  As researcher Steve Farrell pointed out,

"Say that 2 blindfolded men ran across a busy highway and were not struck by a car. Would anyone conclude based on those two events, that it is perfectly safe for everyone to run blindfolded across a busy highway?"

So what to make of all this?  It seems pretty clear that the substantial mortality benefits of aerobic exercise are conferred even after relatively small amounts of running--which is great news for the sedentary population and light exercisers in general--and I'd agree that at some point we reach a rate of diminishing returns, where further increases in mileage or intensity don't offer any additional mortality benefit.  But where that point lies has not been clearly defined, and I think that based on what we currently know, fears of increased mortality as a result of exceeding that threshold appear unfounded.  And generally, most of us who are interested in exploring our physical limits are doing so for reasons that go beyond "living longer."  As Amby Burfoot points out,

"Many aspects of exercise and running also follow a U-curve. This is why many people believe the moderate approach is the smartest path to follow. Of course, you’ll never qualify for the Boston Marathon that way. We all have to make our choices."

Certainly we don't need to run ultramarathons experience all the health benefits of regular exercise.  But it doesn't seem like we need to fear them either.

Monday, October 2, 2017

Race Report: Mountain Madness 50K


It's been a bit of a slog this summer.  After a decent spring and a solid (if slightly unsatisfying) finish at Cayuga I took a much-needed break from training and from my usual LCHF habits.  The resulting gluttony was fun for about a week; after that it started feeling almost obligatory rather than enjoyable.   I started training again about two weeks and twelve pounds later (not joking), and unsurprisingly it took some time to get the ol' rhythm back.  I set my sights on the Vermont 50 mile for my return to fall racing, then downgraded to the 50K when I realized my fitness wasn't quite up to snuff.  My Achilles really started to flare up in early August; by mid-August I was hobbling on most of my runs and wasn't planning on racing at all for quite some time.  Getting off the pavement and back on the trails, as well as back to regular visits with the great Greg Cecere at Momentum Physical Therapy got me back on track, however, and I logged on to register for VT50 two days before the deadline only to be closed out.  (Of course.)  Casting about for an emergency plan, I found the Mountain Madness 50K in Ringwood, NJ on the same weekend as Vermont.  I hadn't run Mountain Madness (or any of the NJ Trail Series races, for that matter) since a rather infamous day in 2009 (which I won't go into here).  I knew it was a more technical course than I'd usually prefer, but I didn't remember it being all that bad, and figured I'd give it a shot.  My fitness wasn't great, but it was time to get back on the horse and kick-start the training buildup for 2018.

Training this summer hadn't been helped by the weather.  July had been pretty brutal, and while August was relatively mild (although quite humid), September turned almost unbearable, particularly in the two weeks leading up to the race.  Given my fitness level, the difficulty of the course, and the forecast, I wasn't expecting much; I was hoping to run around five hours but figured a 5:30 was more realistic.  The weather did not disappoint; at the 9am start the temperature was already 70, and by the time I finished (many) hours later it would climb to 89 degrees with a good deal of humidity.  I ran the opening few miles with two other runners at the front, a young local named Michael and another runner from Costa Rica who spoke absolutely no English and yet tried to ask us questions about the course as we were running.  (We were not terribly helpful.)  We took turns leading over rolling, minimally technical terrain.  My Achilles was not excruciating, but was tight, and my suspicions that it was limiting my push-off were confirmed when I tripped over a pretty innocuous root and sprawled across the trail, my first real fall in quite some time.  I popped up quickly, though, with just a few minor scrapes, and we continued together until about five miles in, when we came to a five-way intersection where the trail markings had clearly been tampered with.  We ran around a bit, looking for the next markings without finding any, then continued in the direction we'd been heading for about a quarter mile.  At this point we encountered markings that I recognized--we had come back to a hairpin turn at about the two-mile point on the loop; clearly not the right way.  Our Costa Rican friend charged off down the trail again, restarting the loop we'd just run; Michael and I yelled after him to not avail, then gave up and returned to the intersection.  By this time two other runners had reached the same point and were equally as confused.  We spent a couple of minutes looking at the map, trying to figure out where to go.  With no other markings, we headed back the way we had come, the only way we knew to get back to the start/finish, which was also the end of the opening 6.5-mile loop and would serve as AS1.  The four of us came into the AS right at the hour mark, as Rick, the RD, was sending off the 25K runners for their 10am start.  We grabbed some drinks and tried to explain to Rick where the issue was on the course, then started off in a group again to tackle the middle 25K loop.

Our pack of four quickly became Michael and I as we started the first major climb.  The trail was much rockier and steeper than the opening loop, and we power-hiked frequently, passing 25K runners along the way.  We were pretty even running on flat ground; I had a bit of an advantage climbing, but Michael bombed the descents, forcing me to work my way back slowly on the subsequent climbs.  I was being patient, but really wasn't feeling great.  Not terrible, but not feeling a lot of pep in the legs, and certainly more tired than I'd like to be less than two hours into a 5+ hour day.  I pulled into AS2 just before the two-hour mark, only a few seconds after Michael, and left a few seconds before.  I knew the next section would be mostly uphill and thought I might be able to open up a bit of an advantage.  Over the next few miles I felt a bit better, finding a bit of a rhythm and seeming to open up a little gap, but when I checked over my shoulder about a mile outside of AS3, Michael was only about a hundred yards back.  He caught up easily on the tricky descent into the aid station, as we hit the halfway point in just over 2:30.

At this point, I basically felt terrible.  I crammed in some off-brand Coke and a couple of bananas, but really had no motivation to get back out on the trail; the fight had suddenly left me, and when Michael took off I waited an extra thirty seconds or so before leaving the aid station, thinking maybe the impetus of having to give chase would spur me on a little bit.  Long story short: it didn't.  I stumbled badly multiple times over the rocky terrain, overheating the whole way back down and struggling on every uphill.  By the time I got back to AS4 (same location as AS2) almost an hour later I was in full death march mode, and still had nearly eleven miles to go.  I knew third place was not within striking distance, but I had no idea on the gap up to the lead, and didn't really care all that much; I just wanted it to be over.

I felt a little better coming down a major descent about forty minutes later, and started running a bit better again, but a couple of wrong turns sapped my momentum, not to mention my will to live.  I staggered into AS5 at the start/finish at right about the five-hour mark, hamstrings cramping badly, still needing to head back out on the opening 6.5-mile loop again to complete the nightmare.  I'd say I considered dropping out, but that's not really true.  I was basically resigned to my fate: I knew I was going to finish, I just didn't particularly want to.  I took my time in the aid station, knowing that my finishing place was assured and that there was no more aid over this final hour-plus.  After tossing back a bunch of Coke and cramming in some more calories, I grabbed the podcast machine and made my way back into the heat.  The final lap passed uneventfully, if not quickly (almost eighty minutes for 6.5 miles!) and I finally jogged home in 6:18, ultimately only about five minutes behind Michael, who I hadn't seen for nearly four hours.

Not much more to say about this one.  I went in with minimal expectations, and they were met in spectacular fashion.  As the Stranger famously said, sometimes you eat the bear, sometimes the bear eats you.  For this race, I think I'll just be happy to be finished with a long, painful day on the trails, take my lumps, and move on to the next one.

Monday, September 18, 2017

Guest Blogger: A Cayuga Trails Recap from Phil Vondra

all photos: Joe Azze
It's been a little over three months since my last race at the Cayuga Trails 50 mile, and I'm just about ready to get back on the horse.  My training partner Phil, with whom I've shared many, many miles, finished just a few minutes behind me there, and returned to racing last weekend with his second straight runner-up finish at the famed SOS triathlon.  This week he sent me his CT50 race report for some reason, and as he doesn't waste anyone's time with a blog, I offered to waste some more of my readers' time by posting it here.  So, here's Phil's slightly delayed CT50 recap.  I think you'll like it.  It's kind of like a race report on acid.  Picture a drunk British guy telling you about his last race and you've got the general idea.

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Race : Cayuga trails USA 50 mile trail champs.  3 June 2017 Ithaca NY

Goals:
  • Improve on 2016 place and time.
  • Eat, drink beer and hangout with a bunch of cool ultra runner type people.
  • Hangout with Laura Kline
Loop 1

We arrived at the park with about 40 minutes until the start time and organized a drop bag for Buttermilk Falls with some spare bottles and nutrition in it. The weather was perfect and glowing red/pink cotton ball clouds drifted over our heads, today would be a good day to die. I lined up 4 or 5 rows back and found Jay my New Paltz running buddy. Ian said a few words and then blew the rams horn, we were off. We set off at that quick pace that almost every race starts at and we hit the first small hill, I backed off and started to think about the miles that lay ahead. Jay and I ran close to each other and chatted a bit. The trails where nice rooty, rocky and rolling, the miles passed easily. We hit the new loop which added some vert but also some fun trails. I was jumping over a few logs which was fun but I knew in 5 hours each one would be a cunning trap just waiting to send me face first into the dirt. We ran past the Old Mill aid station, no need to stop. We headed to the first river crossing, it didn't have as much water as i expected and it was actually nice to get my feet wet. Let the squelching begin! 

The miles passed quickly and the trails were really nice rolling forest rooty and soft. Jay was in front of me and was running the steady smooth pace he always runs. We headed down to Underpass aid station and onto the easy single track and river crossing, I thought the crossing would be deep and was expecting it to be waist deep. Jay was ahead of me and I figured he would go in head first but it was kinda shallow so sadly no fun. We popped out the other side and cruised to the base of Lick Brook climb, I felt great on this climb, but kept a lid on it, knowing that these trails wouldn't give up a finish without a fight. We got to the top and started to roll through the forest and fields. I knew some of this course would be muddy but so far it was in great shape. Rolling along and chatting to Jay we missed a turn and ended up next to a farm and a pig pen, when I heard the banjo playing I knew we had over shot our turn. We did a 180 and ran back to find the turn we had missed. Running with Jay is like being with an able-bodied House MD, so i was probably riveted by some intense medical chat and didn't see the big red arrow telling us to enter into Mirkwood. 

Into the wood we went, it was wonderful mudfest everything an East coast runner wants. Jumping rooty and muddy ground I prayed my shoes would stay on my feet. We emerged onto some grassland with the odd mud patch. At this point I felt hungry and wasn't sure why, I had been good with nutrition and fluid, it was odd but I figured my body was giving me fake news and I would go all in at Buttermilk Falls AS. We headed to Buttermilk Falls, all was good. When we hit the aid station, I took on about 450 calories and some fluids, we got in and out very quickly. The climb up Buttermilk Falls was harder than I thought it would be but I kept my legs moving, spurred on by the fact my T-shirt had turned into a weapon of mass destruction. It single-handedly contravened several international weapon and pollution treaties, but I was racing I had no time to hand it over to the appropriate authorities. The waterfall is beautiful and the trails are perfect. I saw my buddy Tim at a merge point and he was looking good, that gave me a nice boost.  We headed back through the muddy forests and fields along the rolling descent, over the way too shallow river and back to Underpass AS.  It was time to go the dark side.

“Coke please.” 
“More Coke.” 
“Just one more Coke.  What's the worst that could happen?” (I have Youtube, I know the worst that can happen, especially if you're a tooth, a coin or a Mento!)

Fully loaded on sugar and chemicals, I set off again hanging just behind Jay. I took a fall but the ground was soft and I was fine. I felt it was a bit early to be falling.  The trails are good, the Coke is working, I felt great. We hit that big flight of stairs and I felt a bit weak but not too bad. The descent felt good and we headed along the trails to the river crossing and back to Old Mill AS. I got some Coke and ginger ale, the more sugar the merrier! We set off for the turnaround, some easy trails, some rocks some roots but it was fun, until I had another fall, this was a type 3 trail running fall, you don't see it coming, all you know is you're on the ground and you're cut and you hurt but nothing was broken or twisted (well, no physical part of me), I got up and felt ok but not great, I felt a bit sick. We ran into the turn around and I grabbed a few things, forgot a few things and lingered deciding if I should run back to my drop bag. I felt quite sick and weak at this point, so I figured I would just get back to running.

Loop 2

Jay was gone. I wasn't feeling great, I was sure I would be sick. It wasn't an exciting prospect. I also felt weak/dizzy running through the new loop near Old Mill. I knew that if I kept going it would pass. I got to the Old Mill AS and had some more Coke and ginger ale. Shuffling on the easier trails felt ok but I wanted to walk now. The internal battle was raging, "Just walk you'll feel better"; "Why walk on the flat or downhill that's silly;” “ A 15 min mile is better than a 20min mile;” “I'll run flat and downhill and walk ANY hills- that's the deal otherwise all the beer will be gone when you finish- lets go”...so on I went feeling kinda sick but pushing as best as I could and sticking to the deal my mind had made with my body. 


I crossed the river and wanted to sit in the water for a bit. I didn't, I pushed on. Up and down a few hills, I got a bit lost, I turned back and went down a hill I had just walked up, I saw a runner coming towards me and they confirmed I was on the right trail. All good, back to the struggle. The miles passed more quickly than I thought they would. I got to the Underpass AS and gorged on that sweet dark nectar! Off I went over the tracks and through the river. I got to the Lick Brook climb and I was slow but just as slow as the other runners already on it. I was starting to feel better, I was going to finish strong. I found extra strength knowing that I had passed that epic low and what lay ahead would be better. I was starting to overtake people and getting stronger. I felt strong running through the muddy field and forest, jumping roots and dancing around shoe stealing mud pits. Stairs, rocks, roots it was all passing by me now, I had sub 15 miles to go. The T-shirt was excited too, it often reminded me, it had gone from awful to suggesting that it was a close relation to a long lost ancestor who was responsible for the London plague and the rats where purely minions in a grand scheme. I thought about ditching the T-shirt but it wouldn't have been fair to leave it at at aid station that didn't have a hazmat team on standby. I would have to finish with it. 

Phil with Laura and Tim at a happy finish line.
I got to Buttermilk Falls AS. Coke, Ginger ale and watermelon. I was homeward bound, I was strong, climbing the falls felt good but I wanted to get into the cool waters. On I pressed running flats, downhills and small hills, i was overtaking people. I was going to enjoy the last 10 miles. It was nice to get encouragement from other runners and people out for a hike, it really helped. Coke and Ginger ale at every aid station, I got to Old Mill and was told 5k to the finish, time to give it my all. I got just passed the AS to the stone bridge and the volunteer said 2.6 miles to the finish, heck yeah I eat 2.6 miles for breakfast. The miles passed quickly. I overtook the lead woman and she said “you go girl” and then said “Oh sorry you're not a girl!” I wanted to say something witty/encouraging as a response but I had nothing. I got on the downhill back to the finish and felt great, took the left and ran to the finish. I had so much energy I sprinted to the line to finish a shade over 9hrs. I was happy and Jay told me I was 16th! That was better than 2016 and I knew that lots of beer was left! I got to eat and drink beer with some awesome trail people.

Summary
16th place, 9hrs 13 seconds (my time was slower than 2016 but the course was longer and had more gain)
1st AG 45-49
The new course was amazing, it had everything.

What did I learn  the advice i got from an ultra runner a while back was so true on this day. “You're going to get lows, everyone gets lows, you have to believe they will pass because they will.”

Thanks Ian and your volunteers you put on an amazing race!

Gear used
Salomon shorts
Hoka One One Challenger 3ATR
Patagonia T-shirt and its 20million microbe friends
Injinji compression socks
Salomon 2L vest
Huma gels
Tailwind
Coke
Ginger Ale

Thursday, June 22, 2017

Running and Your Heart, Part III: Coronary Artery Disease

Coronary arteries, as seen via cardiac catheterization.
photo: pinterest.com
Before we get into it, let's just reiterate that this post (or anything else you read on the blog) is NOT to be construed as medical advice.  This is for informational and general-knowledge purposes only.  Furthermore, while I have a pretty good grasp on this stuff, I'm NOT a cardiologist, and anything you might read here is subject to my own interpretations (or mis-interpretations).  As such, this blog should not be taken as a substitute for medical care by a qualified professional.  I'm happy to provide information and try to answer people's questions.  But I AM NOT YOUR DOCTOR.

That being said...this blog is getting awful science-y.

In my continuing effort to either confuse the shit out of you, or freak you out (no, no, JK), I thought we'd delve a bit more into the relationship between distance running and heart health/disease by focusing on the coronary arteries.  Last time I talked about the normal adaptations the heart makes to endurance exercise ("the athlete's heart") and how these adaptations can be both beneficial and, in some cases, harmful.  In that post we quickly glossed over the coronary arteries, but today we're going to examine that aspect of the cardiovascular system in greater detail, because it's extremely important and because a lot of recent research has examined this relationship closely.


photo: pinterest.com
Recall from last time that the arteries carry oxygen-rich blood from the heart to the various muscles, tissues, and organs of the body, supplying them with the oxygen necessary to perform their particular functions.  The coronary arteries run directly over the heart muscle itself, bringing oxygen to the heart tissue and allowing the heart muscle to fulfill its ceaseless task of pumping blood throughout the body.  Given the heart's position of primacy in the body, you can see how the entire system relies to large extent on the uninterrupted flow of blood to its muscle.

As discussed previously, the term "heart disease" can encompass a wide variety of problems with the various physiologic systems at play in the heart: anatomic, structural, electrical, etc.  But most commonly, when someone refers to "heart disease," they mean an abnormality within the coronary arteries that compromises the flow of blood and the delivery of oxygen to the heart muscle.  This can take the form of stenosis, a hardening and narrowing of the artery that can disrupt blood flow.  Such narrowing occurs when various junk, usually cholesterol, builds up within the lumen of the artery.  (Picture a pipe or a hose that gets clogged with dirt and how that affects the flow of water through it.)  Over time, these plaques can harden and calcify, causing the artery to narrow and stiffen.  These stiff, narrow arteries thus lose their ability to dilate (expand) in response to an increased demand for oxygen--for example, during exercise.  So when a heart with narrow, inelastic coronary arteries is placed under the stress of exertion, the arteries cannot expand to meet that increased demand, and the heart muscle suffers from a lack of the necessary oxygen, called ischemia.  (This is the most common reason someone would have chest pain with exertion, also termed angina.)  Sometimes, a piece of these plaques can break off and become dislodged from the inner wall of the artery, travel downstream, and get stuck in a narrower part of the artery, causing a near-complete or complete cessation of blood flow to a particular part of the heart.  If prolonged, this can lead to infarction, or death of this part of the heart muscle: what is commonly known as a "heart attack."

So why do people get coronary artery disease?  Well, part of it is genetic; if your parents or siblings have coronary artery disease, you're more likely to suffer from it as well, and obviously you can't do anything about that.  But there are many modifiable risk factors for coronary stenosis, such as high blood pressure, diabetes, and smoking, that you can do something about.  And running helps with these factors: regular aerobic exercisers have lower rates of high blood pressure and diabetes, and are less likely to smoke.  But here's the kicker: despite the fact that distance running unquestionably reduces your risk factors for coronary disease, it may not actually reduce the chances of developing coronary disease.


CT scan reveals calcification of the coronary arteries.
photo: umm.edu
One of the problems with standard screening tests for coronary artery disease--namely, EKGs and stress tests--is that they are not particularly sensitive in detecting underlying coronary disease among fit individuals.  A routine exercise stress test aims to induce strain on the heart by gradually increasing the heart rate via exertion in a laboratory setting; patients are then assessed for symptoms of heart disease, or changes in blood pressure or heart monitor patterns.  For regular endurance exercisers, the limitations of this test are obvious.  If an athlete is increasing their heart rate via exercise on a daily basis without adverse symptoms, why would any abnormalities appear when she does it on a treadmill, in front of a physician?  However, in the past decade advances in technology have made high-resolution CT scanning widely available for the detection of underlying coronary artery disease.  A CT scan is not without downside--it does involve exposure to ionizing radiation, which is carcinogenic in high doses--but this modality can help identify at-risk individuals who might otherwise be missed by more traditional assessments of cardiovascular health.

Applying this test to an athletic population, researchers have discovered some surprising findings.  Despite having a lower incidence of hypertension, diabetes, and obesity, long-term marathon and ultramarathon runners actually have a higher incidence of coronary artery calcification than non-exercisers in the general population.  (Interestingly, runners who regularly train and compete at shorter distances do not demonstrate this finding.)  This paradoxical relationship has been reported as early as 2008, and has been validated several times since (including by yours truly and colleagues earlier this year).

Why does this happen?  We're not really sure, though several theories have been advanced that might account for this process.  One idea is that repeated high-intensity aerobic efforts subject the coronary vessels to more turbulent blood flow, which over time can lead to chronic inflammation and calcification.  Free radical formation, causing chronic oxidative stress, may also play a role. 

So, does this mean we should all stop running ultras?  Not necessarily.  No one has demonstrated as yet that this increase in coronary calcification leads to an increase in clinical signs of heart disease, or to an increase in mortality (we'll address this further in a subsequent post).  There is some thinking that the calcifications commonly seen in long-term distance runners are firmer and more stable than the softer plaque often seen in the general population, and therefore less likely to break apart and cause the downstream problems I talked about earlier.  Also, research demonstrates that long-term training leads to larger coronary arteries, with more ability to dilate (open up) than those in untrained subjects.  This might serve to counteract the narrowing effect of coronary calcification.  (If your hose is getting clogged, make the hose bigger, and water will be able to flow through more easily.)


OK, this isn't the most reassuring post of all time.  But let's sum up with what we actually know:

  • long-term endurance exercise reduces your risk of high blood pressure, diabetes, high cholesterol, and obesity.  Since heart disease is only one of the issues that can arise in people who suffer from these ailments, this fact alone is probably reason enough to keep training.
  • despite this, people who regularly train for and participate in marathons and ultramarathons appear to have a higher rate of coronary calcification than those who don't.  
  • this higher incidence of calcification may or may not be clinically relevant.  But all things being equal, you'd rather it wasn't there.
  • even runners with higher levels of coronary calcifications may not show signs or symptoms of disease, and standard screening tests may not pick up underlying disease in these people.
Therefore, my take-home point is not that we should all freak out and stop running.  But we should realize that we're not immune to coronary artery disease, even though we are invariably "healthier," on average, than non-runners.  For those of us entering our masters running careers, and who have been at this for several years or more, we should be cognizant of this risk.  Talk to your physician about the pluses and minuses of a CT scan of the coronary arteries, particularly if you have a family history of coronary artery disease in a close relative.  And check back next week when I'll tackle the "running versus mortality" question and try to debunk some of the negative press coverage you may have seen recently.