How Far Is Too Far?

Small town boy turned global technology hero, Ranjan Das died suddenly on October 21 at the age of 42. This event has shocked the corporate world. As MD of SAP India, Ranjan was seen as a quality candidate to one day become CEO of SAP global.

More insidiously, the shock comes as Ranjan represents that jet-setting, highly accomplished and frantically fit person that many of us are or hope to become.

Ranjan had a penchant for running, not just one of the largest enterprise software companies, but also marathons. He was, perhaps, also the quintessential child of the global day. According to a former associate, Ranjan would often shut his eyes after a conference call in California to open them a few hours later to a call in Singapore. When questioned on how he would maintain his schedule, he would say, “I do not need much sleep.”

Like many of us who try to balance our hectic professional lives with sports and exercise, Ranjan was known to be a die-hard fitness enthusiast. A former associate told us that Ranjan would spend at least an hour on his fitness every day and would not miss his routine for anything. After a red-eye flight to Singapore, he would hit the gym instead of the sack, and bounce from there directly to a business meeting.

Maybe his work-outs just lacked the endurance activities that get the blood pumping? Nope. Ranjan’s fitness regimen had a lot of cardio. Did he eat poorly? No. He was very particular and ate only small portions of healthy, non-greasy foods. According to his associate, however, he did face a lot of stress.

“The last four quarters have been stressful for every executive at his level. There was a stress of expectations with India being a key country for SAP.” While it is tempting to blame his death on stress, he was not a very high strung person. “He was just like rest of us.”

The fact that Ranjan was like the rest of us leaves many important questions for us all.

Ranjan died shortly after a work-out. Can endurance activities such as exercise and running do more harm than good? Why do people suddenly die while running or exercising? How do we find out
if we risk such a fate? And finally, what can we do to lower our risks of sudden cardiac death?

We are not the only people asking these questions. Sudden cardiac death from endurance exercise has been making headlines again lately. In the last month, six runners suddenly died in marathons in Detroit, Baltimore, and San Jose. This has brought responses across the spectrum.

A former Detroit marathon director suggests that runners need to take the responsibility for constantly monitoring their health so “tragedies like this do not happen.” Dr. Rajat Chauhan, an ultra-marathoner and sports medicine specialist in Delhi is of the opinion that running clubs and race organisers need to play a more active role in the health of their runners. He suggests that marshals should be placed throughout a marathon to pull out runners that they feel are not doing well.

Dr. Donald Redelmeier from the University of Toronto studied data on over three million marathon runners to ask if running a marathon is more dangerous than something usually less strenuous: Driving a car. His results show that not only is running safer than driving, but that marathons are overall good for society by saving lives as they block vehicular traffic over the 42 km course of the race. If you are a runner and your faster friends tease you about how long it takes you to finish a race, you can now tell them how you are doing your bit for the society.

Dr. Chauhan puts the risks for sudden death at one per 200,000 runners per year. He cautions misinterpretation of those numbers. “It doesn’t mean that every 200,000th person who runs will die,” he says. “You may not have any deaths for a while and suddenly after 600,000 odd runners you might have five deaths together.”

On running and exercise being good for the body, the data is unequivocal. The Harvard Alumni Health Study and Nurse Health Study followed individuals over many years; they both found that physical activity reduced the risk of heart disease and death by 30 percent. In fact, even small amounts of activity, like taking the stairs instead of the lift, showed benefits. Other studies have shown that elderly men who engage in walking two miles or more a day have nearly half the mortality rate of those who walk less than a mile a day.

If running and exercise are so good for us, why do some people suddenly die from them? The answer to that is non-obvious. One of the greatest risks of running and fitness is its benefits.

Let me explain.

You look at yourself in the mirror one day, don’t like what you see and join a gym. The treadmill becomes your friend. This improves your cholesterol levels and lowers your resting heart rate. You (and your doctor) think you are in great health. But these good tests actually conceal the fact that you have clogged coronary arteries. Studies have shown that exercise does not change your life-long risk factors that could be due to hereditary causes. In fact running on a whole lot of atherosclerotic plaque could be fatal.

Endurance exercisers over 50 can die from sudden cardiac events caused by bad stuff called plaque, a deadly combination of cells, cholesterol, fats, and tissue that builds up in arteries. We all have some plaque in our vessels. When in the arteries of the heart, they are most dangerous. Under various conditions, including extreme physical stress, plaque may dislodge from the vessel and cause a traffic jam to the heart or brain, keeping away blood and the vital oxygen it carries. This state of low oxygen would cause pain or angina in most adults.

However, fitness freaks would have improved collateral circulation that gets blood and oxygen to the heart, concealing the underlying risk. They run on. In fact, majority of sudden deaths occur in the very last mile of a marathon. This is the paradox of endurance exercise: Its greatest benefits could prove to be the deadliest.

A study that analysed cardiac markers of marathon runners before and after a race showed surprising results. The levels of a very specific cardiac marker, troponin T, were shown to increase after running. If you were to run into an emergency room with an elevated troponin T count, that would buy you an immediate visit to the angiography suite. Whether this means that runners are permanently damaging their hearts with each marathon is unclear. Dr. Nader Rifai, Professor at Harvard Medical School and Editor in Chief of the leading journal of Laboratory Medicine, Clinical Chemistry, says, “These elevations may signify cardiac death, but more likely they show cardiac fatigue”.

This is consistent with a recent evaluation of marathon runners that used advanced cardiac imaging along with labs. That study, presented earlier this year at the International Conference of the American Thoracic Society, showed that despite the elevated lab tests, at one week follow-up the runners showed no continued cardiac abnormalities.

Is there a way to assess risk for sudden death from endurance activities? Most of the research has been done around marathons, and the conclusions are controversial. In small studies, non-invasive cardiac imaging, such as electron-beam CT and cardiac MRIs, have been able to determine the level of plaque build up in vessels and cardiac damage respectively.

As in all decisions on the utilisation of technology, when science shows that the stuff works, clinical judgment needs to answer when it should be used. No diagnostic tests to date are able to simulate the extreme impact that a marathon has on the heart. According to Dr. Chauhan, “other than screening not being good enough to predict sudden death, it is not very practical to do so for several thousand people two to three days before a marathon”. Until we have better investigative tools, the best we can do is try to reduce the chances by taking preventative measures.

So, what can we do to lower our risks? That one is obvious: We should stay active!

While some of us advise running barefoot, that does not mean you should jump out of bed tomorrow and start on your first 21 km run. You should start endurance sports early in life and not let plaque build up in your heart in the first place.

If it is a bit late for that, before you decide to become an endurance athlete, you should visit a sports medicine specialist and work your regimen up gradually. Run hard, but run often.

Ranjan Das worked and played hard. Could that have been a killer combination? As in most other cases of sudden death, it is unlikely we will find out for sure. We do know, however, that stress — physical or psychological — plays a central role in sudden death. The body often responds in surprising ways to stress. If you begin to do squats, blood will rush to your thighs to give your tiring muscles more oxygen. That is the response to physical stress. Now if you were to sit down at your desk and hyperventilate in panic over a business situation, blood would also be diverted to your limbs.

The physiologist Jay Kaplan did some cool experiments to show the effects of stress on the heart. Kaplan reared monkeys in a situation that gave them high levels of social stress. Even if the monkeys ate well and were active, some of them formed significant amounts of plaques in their coronaries. The fact that not every monkey developed heart disease underlies the important role that genes play in susceptibility to bad coronaries.

A healthy, unstressed person can respond to acute physical or psychological stress by speeding up the heart to get more food and oxygen where needed. If someone is under chronic stress, this response is blunted. Instead of dilating, the arteries will constrict. The body is unable to compensate for the added demand and bad things can happen. When the chronically stressed lawyer jumps up to object to a flagrant violation in court, that emotional stress may give him a fatal heart attack. The same outcome could happen if the lawyer jumps on the treadmill and pushes his body beyond its limit.

In his book, Why Zebras Don’t Get Ulcers, Robert Sapolsky suggests ways in which we can reduce our stress levels; his favourite is frequent exercise.

An important qualifier to exercise is that when it’s used to combat stress, its mood enhancing and physiological stress-busting impact will last for only a couple of hours. Meditation is another way to reduce stress hormone levels. A caveat to this is that the benefits definitely show during the meditation session, but may not continue for long. Social support is another way to moderate stress. This is not equivalent to being social. Studies of animals have shown that when put in social groups, stress levels actually increase as the animals struggle to compose their social hierarchy. The operative word is “support.”

Overall, it is important not to overdo exercise, stress or even the above stress-busting activities. Often doing too much is worse then doing nothing at all. Sometimes even one more mile is just too far.

With inputs from Shweta Bagai, Rohin Dharmakumar and Neelima Mahajan-Bansal

Dr. Kumar is a graduate of Harvard Medical School and Founder and Vice President of Doctor Kares Hospital.