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Patient Perspectives: Long-Distance Running and Mountain Biking in Permanent Atrial Fibrillation

Michael McCullough, Afibrunner.com

Michael McCullough, Afibrunner.com

Being in persistent atrial fibrillation (afib) is sort of like being a pickup truck with a four-speed manual transmission, but you can only use second and third gear.

I’m a 55-year-old distance runner and mountain biker in permanent atrial fibrillation. For the first year or so after being diagnosed I was relatively asymptomatic, except for a markedly slower running pace, and the only medication I took was Pradaxa. However, about a year ago, I began to develop tachymyopathy, my ejection fraction was decreasing, and I was put on a beta blocker (carvedilol). Athletes hate being on a beta blocker, but then again, we hate heart failure more

I’m a podiatrist who works at an orthopedic clinic in Klamath Falls, Oregon. Prior to that, I worked for 20 years as a podiatrist at a family practice clinic. I’ve been blogging about atrial fibrillation and endurance sports for the past two years — my goal is to blog as an afib athlete, not as a health care provider, since cardiology is not in my scope of practice.

I am unsure how many marathons I have completed, but it’s more than 15. I’ve trained for three 50K races (that’s 31 miles), but was only able to run one of them. I was discouraged to participate in my first 50K by my electrophysiologist (more on that later). I completed my only 50K six months later, and a year later, I trained for the same 50K again, but switched to the marathon distance at the last minute because I just wasn’t feeling strong enough on race day.

In 1994, I had surgery to repair my mitral valve (severe mitral valve regurgitation with severe left atrial hypertrophy). At the time, I was mountain biking six days per week. My procedure was a repair, not a replacement, so I have all my original equipment. Regrettably, the left atrial hypertrophy never resolved, and I continued developing arrhythmias (PVCs, PACs, SVT), and ultimately, permanent atrial fibrillation. 

I have been told that in my specific case, an ablation procedure would likely have a less than 30% chance of being successful, and even if it were successful, it would probably not be for more than five years. In addition, I admit that I’m a little gun shy regarding ablation, as one of my former partners at the family practice group, also a distance runner, died from complications of an ablation for his permanent atrial fibrillation.

My primary interest is in trail running, and I’m fortunate enough to live in the Cascade Mountains — the Pacific Crest Trail (PCT) is a half-hour drive from my home — I did two 10-mile runs on the PCT just last week. I was never a fast runner, even in my youth. I’ve always been a big, slow runner (over 6’ 3”, 200+ pounds), but now I’m ridiculously slow. However, one of my greatest joys in life is moving on a trail through the woods or desert, on foot or on a mountain bike. I’ve slowed down considerably since the onset of atrial fibrillation, and even more so since I started the beta blocker — but that is my new reality.

Atrial fibrillation is common in athletes, particularly middle-aged endurance athletes, many of whom, like myself, continue to participate in endurance sports — perhaps now a little slower than before atrial fibrillation. I’d guess that it’s probably more difficult to get an endurance athlete to stop training than it would be to get a couch potato to start running.

I imagine that a lot of the athletes who read my blog are people who have had episodes of atrial fibrillation, or who go in and out of atrial fibrillation. I think people with intermittent atrial fibrillation become much more symptomatic and have a lot more trouble with training. I’ve read accounts of athletes on their hands and knees, gasping for air when atrial fibrillation strikes, ultimately being hauled away in an ambulance. At least in my experience, I have found that although I’m in permanent atrial fibrillation, I have stabilized and am still able to train, just at a slower pace.

In fact, I was delighted to get a medal for second place in my age group at the 2012 Bizz Johnson Trail 50K, which I ran while in atrial fibrillation. It was the first year there was a 50K at that event, and there weren’t very many participants. I’m pretty sure that there were only two people in my age group, but I think that still counts!

While at my previous job with the family practice group, anytime I wanted an EKG or a Holter monitor, I’d have the tech do one on me. I had a fairly long history of arrhythmias, but one Saturday when I returned from a 20-mile trail run, I was in a particularly persistent arrhythmia, felt lousy and weak, and wondered if it was atrial fibrillation. 

On Tuesday, the tech performed the EKG, and my suspicions were confirmed.

At that point, I walked down the hall and went to see my primary care doctor (one of my coworkers), and she recommended Pradaxa, gave me some samples, and made an appointment for me to see my local cardiologist. Why Pradaxa? I had a previous history of a wide range of INRs on coumadin after my heart surgery, I had migraine headaches almost daily while on coumadin for six months, and I am on a vegetarian diet.

My cardiologist, with whom I have been a patient for the past 20 years, examined me, did a stress EKG, told me to continue with the Pradaxa, and advised that I see an electrophysiologist for consultation.

I will admit that I was extremely nervous about my appointment with the EP. I was afraid that he would tell me I had to quit running and mountain biking, and put me on an antiarrhythmic and beta blocker. Or, at the very least, he would tell me to quit running marathons and start doing 5Ks. 

Like other endurance athletes, I often have to deal with people that really don’t understand what it is that we do and why we do it. It is one thing if it’s a relative, friend, or acquaintance, but when it is somebody who is going to formulate a treatment plan that will potentially affect the rest of your life, it can be a scary proposition.

So when I did a Google search on this electrophysiologist, I honestly wasn’t interested in where he graduated from or what he did during his fellowship — I just wanted to figure out if he was a runner, bicyclist, or triathlete. The little blurb about him and the clinic website didn’t mention anything in particular, but in his photograph he appeared to be a thin man, and I found that to be encouraging.

I think I even searched local race results looking for his name, to no avail.

When I called to make the appointment, I asked the receptionist, “Is this guy a runner, or anything like that?” She told me she had no idea.

It took a while before I could get an appointment, and in the meantime, I had a question. I had spent four or five months training to run my first ultramarathon, the Bighorn Mountain Trail 50K in Wyoming. Even after I was diagnosed with atrial fibrillation, I continued to train for this race. I was getting mixed messages from people as to whether or not I should run it. My primary care physician, who is an ultra runner and has completed a couple of hundred-mile races, and who was also signed up to run the 50-mile event at the same race, told me to run it. She said it might just take me a little longer — no problem. A friend of mine with whom I was going to run the race (his first 50K as well) and who is a family practice physician in Wyoming, told me to quit complaining and get on the plane to Wyoming. My cardiologist in Klamath Falls advised me to quit running marathons and not to consider running an ultramarathon. I also have a cousin in Chicago who is an electrophysiologist — he runs marathons and his wife runs ultramarathons — I spoke with him on the phone, and he said I should run it. 

Because of these mixed messages, I decided to call my electrophysiologist and ask him about it. He would be the tiebreaker, even though I hadn’t actually been seen by him yet.

I was able to get a message to him, and his office called me back and said I shouldn’t do the ultramarathon. So I didn’t run it, which was unfortunate considering all my training and paying the non-refundable entry fee (not to mention buying an airline ticket).

However, I didn’t want to waste all that training, so I decided to run a regular marathon that same weekend. I found a nearby race in Vancouver, Washington, and ran that while in persistent atrial fibrillation. I’m sure if I would have asked my electrophysiologist about running the marathon, he would have advised against it, so I purposely avoided that question. It was slow, but I completed the race.

When I finally got in to see the electrophysiologist, he examined me, looked over my EKGs, stress test, and chart notes from the cardiologist, and spent quite a bit of time talking with me.

It was fortunate that my wife had also come along that day, because she wouldn’t have believed me if I had come home later and told her his advice: “Keep exercising like you don’t have atrial fibrillation.” He then went on to advise, “in the future, you may want to consider some moderation as far as your exercises are concerned.”

That seemed reasonable enough. Actually, I was delighted!

I found the next thing he said to me to be kind of funny: “People like you are a type — ultramarathoners, triathletes, Ironman competitors… and you can be pretty hard on your bodies.”

Hmm, well… that’s certainly true.

In addition to clearing me to continue with my running, he advised that I did not need to take an antiarrhythmic, which probably would not be very helpful in my specific case, and did not recommend a rate control drug at that point in time (although I now require the beta blocker). Furthermore, he thought I had a low likelihood of having a successful ablation procedure given the severe, long-term hypertrophy of my left atrium and the fact that the atrial fibrillation was persistent.

He did recommend that I try cardioversion with a “one strike and you’re out” policy — that is to say, it probably would not be any type of permanent solution, but was worth trying at least once. That seemed perfectly reasonable to me, so I went back to my cardiologist to have the cardioversion done, and was in sinus rhythm for a total of 33 days.

I was so pleased with my visit to see the electrophysiologist, that I wrote him a letter afterward thanking him. I hadn’t really expected that kind of empathy.

It was during those 33 days that I realized just how much atrial fibrillation slows me down. Mountain bike rides that were taking me 75 minutes in atrial fibrillation, were taking the 55 minutes in sinus rhythm — even though I did exactly the same trails. I also found I was doing my training runs at a pace approximately one to one and a half minutes per mile faster in sinus rhythm. This is a significant difference. Of course, when I inevitably went back into atrial fibrillation, it slowed me down again.

However, being in sinus rhythm was sort of uncomfortable for me. I felt like I was having PVCs or PACs about every fifth or sixth beat, and these were noticeably uncomfortable. In terms of how I actually feel when I am in atrial fibrillation, I am more or less asymptomatic, except perhaps when getting up quickly to answer the phone. 

I am not happy (or proud) to be in atrial fibrillation, but this is what I have to deal with. Unlike many afib athletes who go in and out of atrial fibrillation, I am always in atrial fibrillation, and I do not expect to ever be in sinus rhythm again. However, I continue to enjoy marathoning, trail running, mountain biking, hiking, and any other outdoor activity for that matter. At least in my experience, I have found that although I’m in permanent atrial fibrillation, I have stabilized and am still able to train, just at a slower pace. When mountain biking, I wear a good helmet, both my wheels remain on the ground, I walk the rocky sections, and avoid the dangerous and steep trails altogether. I am 55 years old with 30 years experience on the bike. I know what I’m doing out there.

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