It’s interesting to read a report, in this case an autopsy report, which reads that the individual died of heart disease that was “natural” when that person was only 58 years old and supposedly in excellent health. I’m referring to the sudden and to some extent, unexplained death of Micah True, also known as Caballo Blanco – the man made well known throughout the world from the huge success of Christopher McDougall’s book Born To Run. He was found dead during a training run on March 27, 2012.
The medical examiner performing the autopsy has deemed True’s death a result of “unclassified cardiomyopathy which resulted in a cardiac dysrhythmia during exertion.” Basically this means that he died because his heart muscle was deteriorating slowly over time and eventually this created the electrical activity of his heart to beat abnormally most likely leading to inefficient pumping of the heart and finally cardiac arrest. Normal? Definitely not. Common? Perhaps very much so.
The examiner further states, “The manner of death is natural.” Sure this is officially classified as “natural” on the death report since he wasn’t shot or had a boulder fall on his head, but dying this way is far from natural. A heart doesn’t “naturally” fail in such a manner, especially at 58 years of age. Though the most common reason for cardiomyopathies is ischemia (lack of oxygen supply to the heart), the medical examiner notes that there was no evidence of ischemia or inflammation of the heart. It’s all a bit strange.
So since there was apparently no ischemia or other cause for True’s heart disease, this could very well leave one to speculate that his condition, and death, was one which resulted from hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy (HCM) is a thickening of the heart muscle and the most common leading cause of sudden cardiac arrest and heart problems in athletes. Those with HCM often have a severe thickening of the left ventricle of the heart, and True’s autopsy does clearly state this. This condition, known as left ventricular hypertrophy (LVH) can eventually result in cardiomegaly – an enlarged, inefficient heart. The medical examiner does note in his review of the cardiovascular system that True’s “heart is enlarged” and further notes “mild to moderate arteriosclerosis”, though he makes no relationship of either condition to his LVH and further back to his HCM – his “cause of death.”
Ultimately True died in the same manner many fit but unhealthy athletes have died in the past, and unfortunately many more will succumb to the same fate in the future. In 2007 during the Olympic marathon trials, 28 year old long distance athlete Ryan Shay collapsed and died from a heart attack. He, like True, also had cardiac hypertrophy, and subsequently cardiomegaly. And like Caballo Blanco, his final autopsy notes that he too died of “natural causes.”
I can assure you one thing – dying from a heart attack due to prolonged, chronic structural changes in your heart is far from normal and further from what “natural” really is. A thickening and scarring of cardiac tissue is the result of the body’s inability to keep up with prolonged and excessive stress demands – essentially it’s in constant repair mode, and losing. Shay had this process occurring in his heart (fibrosis) and True in his arteries (arteriosclerosis). These “osis” conditions are due to free radical damage, inflammation (even temporary, but frequent), and hormonal and metabolic problems that occur from training too hard, lack of rest, improper diet, and other lifestyle factors.
In Part V of the Sock Doc Training Principles I go into further detail how and why highly conditioned athletes are dying from chronic endurance training and steps you should be actively taking now so you too don’t all of a sudden die from a “natural cause” such as a heart attack, cardiac arrest, or any other disease or disorder in which your body can no longer keep up with the demands you place on it.
Jeff Gallup says
Interesting, because a 58 year old woman just died of cardiac arrest on Monday on the Manitou Incline, a strenuous climb that is very popular near Colorado Springs. Initial thoughts were that she was not in shape to do the climb, but she was a PE teacher, very active, and a veteran of the annual Pikes Peak Ascent (1/2 marathon to the top of the Peak). Coroner states it was natural causes, but I question that, just like with Caballo… doesn’t seem natural at all, and at 48 I don’t like hearing about athletes dropping like this.
So I understand your thoughts on how to best avoid this (I pay very close attention to diet), but are there ways to know if you have this thickening/enlargement issue? or to know that it is developing? And if so, can you reverse it, or just stop the progression?
Sock Doc says
Sure you can reverse these things – depending on the extent of damage that has been done though. You can definitely stop the progression. I’ve been told (by a MD friend) that you can check for LVH on a standard EKG (electrocardiogram) – a test not typically used on “healthy” athletes here in the US; often in Europe though.
lisa schmidtfrerick-miller says
And let’s not forget SCAD – spontaneous coronary artery dissection. Many of us survivors are fit, active, healthy, with absolutely no risk factor for heart disease. Read more at scadresearch.org.
Jackie Yukawa says
I have a question: I have an enlarged heart with scar tissue. I take antibiotics when I go to the DDS. I also have been asked if I had polio as a child since I also have scoliosis. In college, a Dr. told me I had an enlarged heart and stunted lungs probably due to my scoliosis.
I am now 63 and had a pacemaker put in for bradycardia (electrical: top chamber not pumping fast enough to lower chamber) in 2004 (while training for my 4th ironman). I was actually flat lining but never passed out. In the hospital, they kept running into my room for Code Blue and I would be reading.
I have been a runner since I was 20 and a triathlete since 1987 doing Ironmans too. (Not any more though, bad knees.) So am I am risk for dropping dead of a heart attack? Everyone on my mom’s side dropped dead of a heart attack or stroke.
Sock Doc says
Well I’d say based off the info you provide here – the enlarged heart and scar tissue and pacemaker – sure you’re at “risk.” Family history too. Everyone has some risk factors – even me. So you limit your risk as much as you can – by training right, eating right, resting well, etc.
i have a question: My husband fell while taking a shower and died, the coroner said it was cardiomegaly when he was never diagnosed with a heart disease in good shape at age 50. on the death certificate it says “Natural death” that’s not natural to me. No one knew that he fell till after 30 to 45 minutes that could happen during that time. i just don’t wanna accept the term” Natural”
Sock Doc says
I’m really sorry to hear that happened. You said you have a question but I’m not sure what you’re asking.
Mary Boudreau Conover says
Perhaps at autopsy some measurements were taken in order to distinguish between hypertrophic cardiomyopathy (HCM) and the athlete’s heart. In hypertrophic cardiomyopathy there is increased left ventricular (LV) wall thickness. In the athlete’s heart there is an increase in diastolic LV cavity dimension. Although the differential diagnosis on ECG can be difficult in athletes who train at the elite level, it can sometimes be made solely on the basis of echocardiographic evidence of left ventricular cavity dimension; possibly the same measurements could be made directly in the post mortem exam. Had Micah True had an athlete’s heart and not HCM, we would still not know the primary cause of death.
In more than one third of elite trained athletes the LV diastolic cavity dimension is enlarged to more than 55 mm. However, in most cases of HCM (unless end-stage), LV diastolic cavity dimension is less than 45 mm. Of interest, in echocardiographic studies of 947 Italian Olympic athletes it was demonstrated that only 16 had LV wall thicknesses of 13 mm or more and none more than 16 mm (rowers and canoeists). Eight of the 16 were at the top in the world in their sport.
In athletes younger than 35 years, HCM and arrhythmogenic right ventricular cardiomyopathy are common causes of sudden cardiac death. In athletes 35 years of age or older, atherosclerotic coronary artery disease accounts for most sudden deaths, usually related to distance running and isometric exertion such as weightlifting. Other rare causes of sudden death in athletes are congenital anomalies of the coronary vessels, Wolff-Parkinson-White syndrome, and congenital long QT syndrome.
Pelliccia A, et al: The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes, N Engl. J Med 324:295-301, 1991.
Maron BJ, Araujo CD, et al. Recommendations for pre-participation screening and the assessment of cardiovascular disease in masters athletes…, Circulation, 103:327-34, 2001.
Conover MB: The Athlete’s ECG in: Understanding Electrocardiography, 8th ed, 2003, pp. 253-271.
jeff galbraith says
i have not read anything about his training leading up to his death,that would be of some benefit to know? or not ?
Sock Doc says
The guy trained and raced ultras. I’ll quote Chris McDougall: “This is a guy who could set out with a little bag of ground corn, a bottle of water in his hand and be gone all day. The day before he died, he did a six-hour run.”
Byrren Yates says
First, thanks for this incredible resource – I came here thru your trailrunnernation podcast even though I’m more of a BJJ and MTB guy. I have been using long slow runs (in minimalist footwear) for past couple of years now to build my aerobic base, and have been moving towards a more aerobic life-style once I found out that I needed to get other facets under control.
I had an observation/question about this article and your Principles article #5. I have read that a heavy regimen of anaerobic only style of training could lead to concentric cardio hypertrophy instead of eccentric cardio hypertrophy adaptation brought on by building the aerobic base.
Sorry I’m not a med guy so I know I run the risk of oversimplifying but it seems like this LVN condition is very similar to that concentric cardio hypertrophy brought on by the high intensity interval only type of training that is currently en vogue.
Is that post by Mary above drawing that distinction of eccentric vs concentric hypertrophy when she writes of the diastolic cavity dimension?
If LVN is what is brought about by too much stress/anaerobic lifestyle, then when and how does that adaptation go from favorable physiological adaptation to become pathological? Or can benign LVN adaptation turn pathological at some point in the future due to other genetic and environmental inputs? If so, then it would seem like as athletes we should be doing what we can to avoid that type of adaptation…
Sock Doc says
Hi Byrren – you’re bringing up points that really nobody knows the exact answer to. There are no perfect tests or studies to distinguish between what is pathological and what is physiological especially since you can’t do an autopsy on a healthy (alive) person. When one crosses from physiological to pathological is an uncertain area.
Briefly – by the books and “definition”:
Concentric: increase in ventricular wall thickness with unchanged chamber size in response to an elevated pressure load commonly found in strength athletes. Since blood pressure increase is often the result, many correlate concentric with a pathological condition.
Eccentric: increase in ventricular wall thickness and an increase in chamber size in response to increased demand often found in endurance athletes. Many correlate eccentric with a physiological condition.
But can an endurance athlete be creating concentric changes? Sure – definitely. And can a strength athlete be creating eccentric changes? Sure – definitely again. So you eat well, train smart, consider lifestyle stresses, and do everything you can – especially listen to your body when it’s not feeling well so the odds, regardless of genetics, are in your favor. Yes there are some people that no matter what genetics will take them out at age 50; just as there are some that can do all the “wrong” things and live a crazy life until over 100.
BTW (by the way) – not sure what a couple of your acronyms are here:
LVN – Left Ventricular N?
BJJ – I don’t have a clue (bowling, juggling, jogging??)
Byrren Yates says
Thanks for the reply – makes sense and I’m increasingly aware and trying to modify. Your list of overtraining symptoms parallels other reading I’ve done regarding signs of chronic cortisol/stress overload.
LVN was an ipad typo, I meant LVH – left ventricular hypertrophy
BJJ – Brazilian Jiu jitsu
martin van lear says
Many as you know are bashing long slow cardio because of these deaths and thus going full bore into promoting interval training, citing that these workouts boost muscle growth via hgh release. also near misses like alberto salazar (heart attack) and grete waitz (not cardiac but died of cancer…did oxidative stress play a role?) are cited. also many studies are highlighted, especially the one that showed cardiac scaring on a high percentage of masters athletes who have completed 100 marathons (century club). and then there is a study i think that shows a troponin leak after marathon running, which i believe returned to normal after a period of time. sorry but im sure youre familiar with these studies, if not will pull them for you…just dont have the time right now 🙂
lets assume that yes long distance training puts a stress on our hearts. those with good genetics, diets, and hopefully a wise training regimen will avoid prolonged ischemic injury that might result in scarring. but how does one know if one’s heart is in jeopardy? apparently, in most of these cases, the runner was asymptomatic. i believe the century club runners who had scarred hearts were also asymptomatic. SO… assuming that there are many unknowns, and of course we usually have little idea what our genetic tendencies are, ive always assumed that we needed extra mitochondrial protection when we run…lets face it our mitochondria are under 20X the oxidation stress when we exercise than when we are at rest.. depending on the intensity of course….so one could theorize that oxidative stress could accumulate over many years of training and lead to a cardiac event.
ive often wondered if supplementing with antioxidants before i run, will help to add a certain level of anti-oxidant protection and added insurance…ive been taking up to 300mg ubiquinol, resveratrol, curcumin, and astaxanthin (8mg) before hard workouts. i know there are some studies that suggest this doesnt help, and may possible hurt (cant remember their reasons why…need to dig up those studies…but something to do with blood sugar levels and muscle stress)…so what do you think? would such supplementation help to prevent oxidative stress that could lead to some of these injuries, assuming that your diet is decent and oxidative stress is kept to a minimum between workouts?
Sock Doc says
Nutritional needs are per individual; for the most part there is not one supplement that “protects or prevents” especially for the general population. Ideally you should be getting all your nutrients from foods, but the more you train and the more stress you’re under obviously this can be very difficult. So although I use a lot of nutritional therapy in my office, eating better is still ideal.
Personally I could care less what one study says or doesn’t say about a particular herb. Herbs such as resveratrol and curcumin are so dependent to how they’re grown, processed, and packaged you can get some organic curcumin from your local farmer that is going to be great for your health and another in a bottle with fillers and binders that’s been pasteurized and had chemical processing and it could be terrible for you. So you really need to be careful.
I do like COQ10 a lot though (ubiquinol as you mention – though I don’t think the “ol” form is any better than ubiquinone). It’s hard to get in the diet (meat) and quickly depleted in athletes especially once they hit their 30s. 300mg a day probably more than you need unless you’re very deficient. Though I use that does a lot, and higher, after a while I have the person take 100-300mg a few times a week.
martin van lear says
hey soc doc thanks so much!
i couldn’t agree more…yes, totally agree the whole food strategy is the way to go, but cant help but be greatly influenced by the many studies coming out about select isolated antioxidants that i mentioned. yes how the various ways they are produced has a huge impact. not just that, but how they are absorbed. resveratrol, btw, is best absorbed in the mouth (sublingual), not the gut. most resveratrol is only available orally. also curcumin is very poorly absorbed, even if you do find a good source.
there is an absorbability issue with coq10 as well, this is why i have chosen the ubiquinol form: http://www.lef.org/magazine/mag2007/jan2007_report_coq10_01.htm. i only take it before long runs and training days…its gets quite expensive to take it everyday.
btw, since you mentioned whole food, there was a great article about watercress that came out today… watercress does a great job in preventing free radical production during exercise. gonna eat watercress before every long run now! lol see article link below:
anyway, just want to say i love your website and podcasts…am learning a great deal and very much appreciate all of your wisdom and advice!
Thank you for presenting a rational interpretation of Micahs autopsy. As a runner and a dad, its increasingly difficult to make sound training, nutrition, and performance expectation decisions amongst all the information and contradictory information out there.
Train old school. 10,000 year old school. Run in full awareness how your body is feeling. It feels like slowing down, or even stop, oblige it’s demands. Do not strain too much. Just give enough stimulus to progress, and keep most of your run in extremely easy zone. Maybe once or twice a week nudge a bit up.
Ultra Mad says
Very interesting read… As someone who runs ultra marathons I suffered a MI during a 53 mile race in Scotland in 2011. I had a plaque rupture in my right ventricle which resulted in a blood clot forming when I rested at a checkpoint. Over the past year Ive done a lot of research and reading of white papers on the effects of endurance running and all seem to point in the same direction that whilst running is a great form of exercise you do run the risk of having heart issues at some point. As someone who has been fit and healthy for all my 44 years(so far) I would never have thought that I would have had a MI through over exercising.
Ultra running is a mad sport and very addictive.. more and more road runners/marathon runners are coming into the sport as its become the next best thing for challenging your bodies limits.
Life style is everything diet, exercise, and well being is the way forward in moderation but there will always be people like myself who want to push the boundaries but I do believe people should be made aware of the risks.. to their hearts by over training.
Sock Doc says
Great comment, thank you!
Good day sir , i have a question.can left ventricular hypertrophy be treated with CO-Q10?
Dr. Stephen Gangemi "Sock Doc" says
COQ is an important heart antioxidant but I it, nor should any nutrient, be used to “treat” a LVH condition.