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[0:43] Hi and welcome to my podcast and videocast station. Thanks for tuning in. As always, I really appreciate if you take your valuable time to tune in and listen and I really hope we can provide something valuable for your best health journey today. I believe we will. Today I have with me a special guest from the other side of the world. We're connecting via
[1:13] an assistant professor in...
[1:17] at the University of Chicago in Illinois. He's director of sports cardiology there, and he's also director of cardiac MRI. Hi, Akash. How are you?
[1:30] I'm doing well. How are you? Thanks for having me.
[1:32] Thank you for joining us. I really appreciate it. And I know that lots of people listening will be interested in sports cardiology, but for those who are not cardiologists, what does sports cardiology actually mean?
[1:45] Yeah, I think simply put, it's a specialized emerging field within cardiology, broadly focused on the cardiovascular health of athletes. And, you know, there's a wide range of definitions of athletes, but anyone with active individuals with fitness goals. And, you know, encompasses initially making an appropriate diagnosis using imaging, physical exam history to risk stratification of the athlete once we have a diagnosis.
[2:15] management and coming together with a shared decision making with the athlete and return to play and how to safely do so if appropriate. So in general terms, Akash, would you be dealing with semi-professional and professional athletes? Or do you see many of the run of the mill mums and dads who are just trying to keep fit? It sounds like it's more the upper echelon of athletes and the more extreme athletes you're dealing with. Would that be what you tend to see?
[2:46] No, actually, interestingly enough, it's both. So while we do see some elite athletes at all levels from high school to collegiate to professional, actually the majority of the patients we see are patients who maybe were former high school athletes now in their 40s or 50s are kind of the weekend workout warriors who are having some cardiac symptoms.
[3:16] goals and wants to achieve them.
[3:19] So, I...
[3:20] For some of the people listening, they might be thinking, well, we know exercise is actually good for your heart. So how does it, you know, how do we end up with a specialty of sports cardiology? How is exercise?
[3:34] potentially bad for the heart. Can you do too much? Can it be too intense? Where does that sort of fit in?
[3:41] Yeah, that's a great question. So, you know, I think overall there's overwhelming data that exercise is good for the heart. And, you know, we have no hard data that there's a thing that's too much quote unquote exercise. What we do see is that at some extreme levels of exercise, especially endurance, running and cyclists and male athletes, they have increased risk of atrial fibrillation or arrhythmias is something we can see. So it's all about striking the right balance
[4:11] I would say the way a lot of patients end up in our office, to your point, is a lot of people are told kind of inappropriately that they can't exercise. It's too risky to exercise. They may have a variety of cardiovascular conditions. It may just be someone's on abnormal EKG and they're like, you can't exercise until you talk to a cardiologist.
[4:41] and not how we should approach these patrons.
[4:45] Let me jump in there momentarily, Akash, because you may not know what hypertrophic cardiomyopathy is. Just in a quick word, if I can, and I'm sorry to break your stride. The diagnosis of hypertrophic cardiomyopathy is made when we look at the wall of the heart muscle, the main pumping chamber, what we call the left ventricle, and for genetic reasons, it's thickened, often in a particular area.
[5:13] And the word we use for thickened is hypertrophied. And if the muscle's not normal, we call it a myopathy. So a thickened myopathy is a hypertrophic myopathy. And this can be linked with sudden cardiac death in exercise, which is why if it shows up on an ECG or EKG, if you're in the US, it can be a flag. And that's what you're talking about, isn't it, Akash?
[5:39] Yeah, absolutely. I think you described it well. Simply put, it's an unexplained thickening of the heart muscle. We usually see it, like you said, in one particular area of the wall or one specific area. And, you know, historically, you know, just showing how much the field has changed 20 years ago, it was kind of a class one indication for those patients not to do any vigorous level of exercise.
[6:09] longitudinally that, you know, vigorous activity is safe in these elite athletes with HCM. And we take care of professional athletes with hypertrophic cardiomyopathy as well, who continue to compete in, you know, elite professional sports.
[6:25] Look, one of the things that I'm interested in, and maybe some of those listening could be interested in, is there a difference...
[6:33] for the risks the heart may be under with exercise,
[6:37] When you compare high-intensity or power-type sports versus endurance sports, so a weightlifter versus a marathon runner or Hawaii Ironman, do those two different stimuli give rise to different problems with the heart?
[6:54] Oh, absolutely. That's a great point. And I think, you know, the terms we kind of use are dynamic or static exercise, right? So to your point, the weightlifter's heart is going to look different than the endurance runner's heart. You know, the weightlifter's heart, we may see more an offensive lineman in American football. You may, you know, you may see a little bit more thickness of the walls because of the weightlifting, whereas an endurance athlete, you really shouldn't be seeing that and you get more maybe a dilated cardiomyopathy or the
[7:24] heart chamber itself is enlarged. So there's no question, you know, a lot of our papers and figures is on one, on the X axis, we have dynamic, on the Y axis, we have static, and then we label each sport and different things. And, you know, we're using the extremes of weightlifting and endurance runners, but, you know, basketball players are somewhere in between, you know, soccer, athletes fall somewhere in between, golf is somewhere there. So each different sport has
[7:54] which would change how the heart remodels. Okay. That's interesting. Is that different between different individuals? Do some individuals, because of genetic predisposition, carry greater risk, for example?
[8:08] Yeah, you know, that is kind of, I think, the thing we're continuing to study and evolve. We know that patients with certain genetic mutations, I won't go into too much technical details, but there's some cardiomyopathies where patients have certain genetic mutations where we know that exercise may accelerate that phenotype or may make things worse. And those things are rare. In most genetic conditions, exercise actually doesn't make things worse.
[8:38] specific mutations. So no question genes play a role. But what I would say is that the vast majority of patients, even with a genetic cardiomyopathy, meaning they have a gene, their gene positive for one of these cardiomyopathies or abnormal heart conditions, they can safely do exercise. And our longitudinal data shows that.
[9:00] Okay. Look, one of the things that you mentioned earlier on in the interview was atrial fibrillation in endurance athletes. I don't want to put you on the spot, but I have a vague recollection that...
[9:15] I'd heard that there was a threshold of cumulative endurance training or undertaking endurance activities of a certain number of hours, whether it was 5,000 hours, 10,000 hours, 20,000 hours, that would put even a non-genetically at-risk individual on.
[9:37] at risk of atrial fibrillation. Is there a sort of threshold level that people are starting to appreciate or have I wrongly heard that? No, I think you're absolutely right. I think it's not, these are patients who quote unquote have structurally normal hearts, right? But you put them through extreme endurance activities. We are seeing a signal towards increased AFib. I think the exact cutoffs, you know, those are consistently changing of, you know, exactly how many hours,
[10:07] You know, the patients we see it the most commonly in are like the ultramarathon runners, the endurance cyclist. And it's definitely much more common in males than in females that we're seeing the signal of increased astral fibrillation with significant endurance. So, yes, even if your heart, you know, there's extremes of exercise.
[10:37] streams of exercise. I'll be honest, this is something that's very controversial and kind of a hot topic in the community. And I think we're still studying it quite a bit in terms of, you know, why, you know, my Dr. Warrick not get atrial fibrillation at this level versus if I, you know, if my father did the same level of activity, he may get atrial fibrillation. I think that's still something we're studying. And, you know, this is where imaging may play a role in as well, as well
[11:07] on echocardiograph or cardiac MRI. There's a lot of fancy techniques that we may be used to kind of identify the people who have quote unquote the substrate to develop atrial fibrillation. But yes, your overall point, I think we see that
[11:21] There is this clear signal, and again, it's not everyone gets it, the vast majority of people don't, but there is this clear increased risk of atrial fibrillation with extremes of endurance activity.
[11:33] And if we think about atrial fibrillation as a consequence of this extreme activity, is that related to inflammation and fibrosis occurring in the heart? And what do you sort of see if you undertake a scan of someone's heart? And I'm asking Akash because I know that he's all over cardiac MRI,
[12:03] technology basically using magnets and how water moves to get images and they call we've got a specific um specialty cardiac mri because it's more complex because the heart beats um and i know akash is a specialist in this and and and really a world leader with the publications and things that he's produced so akash here's your chance to
[12:25] Explain a little bit to us, what are we going to see when we put someone in a scanner?
[12:31] Yeah. One of the things that we think we'll see, and again, this has been shown in small studies, but not real large studies, is what you mentioned, fibrosis. And the heart, eventually over time, there can be inflammation and the extracellular or the volume outside the cells can grow and that can manifest what we call kind of fibrosis or some degree of inflammation on the MRI.
[13:01] reverence athletes who undergo MRI. We're seeing that on MRI and we also see abnormalities in echocardiography when we assess the left atrium, that chamber where stretch can occur and people can get atrial fibrillation, that there may be some signs on echocardiogram of what we use strain to detect subclinical dysfunction and we measure different functions of that and that may be
[13:31] So yes, I think we're starting to see earlier signs with the strain on echocardiography and MRI of early fibrosis in these patients, which may predispose to atrial fibrillation.
[13:44] Okay.
[13:44] And would some of these individuals be advised to take fish oil, for example, or would you be more vigilant about their blood pressure, for example? Yeah. Are there other factors that would come into play if you're having a conversation with...
[14:01] with someone who might be at risk of developing atrial fibrillation from their
[14:06] From their love of exercise, actually.
[14:09] Yeah, and I think to kind of go back full circle, I think this is where having some expertise in sports cardiology is helpful because how you would manage an elite athlete with atrial fibrillation is different than how you'd manage someone who's not or someone who's an athlete who just loves exercising. And, you know, the last thing we want to do is take away exercise from those patients, and that's not our intention to do so.
[14:39] And, you know, some of our athletes have had good strategies with what we call a pill in a pocket strategy, meaning they feel they go into atrial fibrillation. They take a certain class of medications and they can get them right out of atrial fibrillation. Some of these patients may benefit from an ablation where, you know, our electrophysiology, those are doctors who we call the electricians of the heart. They can go in and do a catheter ablation and treat the atrial fibrillation.
[15:09] careful with athletes in terms of who we refer to because if they're overaggressive in their ablation, the atrium can become stiff and they may not get that atrial kick that they need with competitive exercise. And then obviously, you know, atrial fibrillation carries a risk of stroke, but I think there's a little bit more nuance in the manager of who you put on a blood thinner, who's an athlete. You know, some of that obviously depends on what sport they play, but
[15:39] to VASC or as you know and briefly for the audience it's how we calculate the risk of someone who has atrial fibrillation being in stroke but you know we don't know if that really
[15:48] holds true for elite athletes. And, you know, if patients only have short runs of atrial fibrillation, can we do a pill in a pocket, oral anticoagulation too? You know, these are all things that are being studied. And I think, you know, having someone who's familiar with these different options and
[16:06] Their response is not
[16:08] to just tell the ultramarathon or not to do ultramarathons. I think that's important. And that's, you know, where I think sports cardiology has a role.
[16:15] Sure. My guess as well, Akash, is the detection of these arrhythmias, particularly for the more serious athlete, is probably improving all the time. I imagine that many of these serious athletes are wearing some sort of device immediately if the heart rate changes or varies or some such thing occurs. So I imagine that might feed into, obviously, the way you care and gives you extra information as well.
[16:44] No, absolutely. The Apple Watches, Fitbits, Carvia devices, they've all, for better or worse, I would say created an explosion of data for us to use. And in some cases, it's absolutely helpful. A patient feels they're in atrial fibrillation. They're in atrial fibrillation within two minutes. They can send me an EKG on their phone. I can take a look at it, tell them what to do. So it's definitely been a powerful tool in our kit.
[17:11] Well, look, this is absolutely fascinating. I know some people who are listening are longer...
[17:18] more endurance athletes. Some will be power athletes. I think our concern with
[17:24] particularly atrial fibrillation fibrosis, seems to be more related to that endurance space. But as we approach the home straight, not to use too much of a sporting pun, but as we approach the home straight and the finish line, what I'd like to raise is this concept of sudden cardiac death in athletes, which is a terribly concerning concern.
[17:47] for participants, but also those watching. And I imagine you break it down into young athletes and old athletes, am I right? Or is there another way you think of Southern cardiac death in athletes?
[17:58] Yeah, I think that's one way to think about it. I think another is just underlying causes. As cardiologists, we kind of break it down into, is this a rhythm issue? Is this a coronary disease issue, blockages in the heart vessels? Is this a cardiomyopathy issue, structural abnormalities of the heart? The one thing I'll say with sudden cardiac death is it obviously gets a lot of media
[18:28] even few years have sudden cardiac arrest but the overall rates of sudden cardiac arrest
[18:35] arrest in athletes is very low there is just a you know recent study that came out in circulation one of our journals and you know they followed male collegiate and female collegiate athletes for a long period of time an exceedingly low rate of risk of sudden cardiac death in young athletes but obviously we want to prevent it and it's anytime it does happen it's obviously a tragedy so
[19:00] you know, in terms of breaking it down, you know, in terms of prevention, you know, the main thing is to have an emergency action plan, right? Any high school athlete, any collegiate athlete, you know, they should be at a place where the trainers know CPR, there's everyone knows how to use an AED, those kind of basic things. And then, you know, it's kind of controversial, but EKG screening when done in the right hands, we think probably is useful,
[19:30] leagues are now also moving to doing ultrasounds of the heart in their athletes too. And then you mentioned kind of the breakdown of young versus old and in that, you know, the most common cause in older people is still probably coronary disease, bread and butter blockages in the heart vessel and still, you know, probably the most common in younger groups too. And then the other causes we think about are, we mentioned hypertrophic cardiomyopathy, abnormal thickening
[20:00] as we think of our arrhythmogenic cardiomyopathies or ARVC, where patients are more prone to arrhythmias, genetic conditions like long QT syndrome and those types of things. And then anomalous coronaries in younger patients too, meaning generally the arteries that supply blood flow to the heart come off the aorta or the main blood vessel of the body, but sometimes they can
[20:30] You know, it's something we unfortunately see. I think it's fortunately overall, if we look at an epidemiological standpoint, pretty rare. But there's a ton of research being done for sudden cardiac death. There's still a lot we don't fully understand. There's these people with quote-unquote autopsy negative sudden cardiac death, which is making up a larger majority of these sudden cardiac death cases. And, you know, genetics, channelopathies, these are all things that we're studying in detail.
[21:00] but I think much more to come in the next 10-15 years with this
[21:05] Yeah, no, I agree. Look, uh, before we leave that all together, I have a bit of a soapbox here. Um,
[21:13] And it's around that older athlete, sudden cardiac death. You did mention it. I want to highlight it. Coronary artery disease is the number one.
[21:23] cause in older athletes and we're talking 45 and above approximately. And I really want to shout this out, scream it in fact, so that...
[21:35] The athletes out there who think they're protected from exercise,
[21:39] I'm not. This is so important. I've dealt with athletes over the years. I said, please go and get your heart checked. They go, I will exercise regularly.
[21:48] And unfortunately, exercising regularly doesn't mean you do not potentially put plaque in the coronary arteries. It reduces the risk and it's a good thing to do, but it's no guarantee. So please, if you're an older athlete, 45 and above, particularly if there's a family history, raised cholesterol, any reason why you might be at slightly high risk of coronary artery disease, please get a calcium score and get it checked properly.
[22:17] Yeah, no, I think that's a great point. I think just because you're an athlete doesn't mean if you have high blood pressure, high cholesterol, that all goes away. So we still need to risk stratify you.
[22:47] artery calcification compared to their less active peers. So they have more coronary calcifications, but then if you look at 10 years down the line, their risk of sudden cardiac death or cardiovascular death is not higher. So it is a controversial field, but I think your overall point of, you know, your father had an MI, you have high blood pressure, high cholesterol, just because you're running and exercising a lot. There's no question there's tremendous health benefit to that, but it doesn't mean you still don't need to undergo
[23:17] and seeing your cardiologist. But coronary artery calcifications, atrial fibrillation, these are all topics that are kind of nuanced and controversial in athletes, which I think brings us back to like, you know, seeing a sports cardiologist could be helpful to you.
[23:33] I completely agree. And in fact, for those listening, if you're curious, I have done a podcast on an elevated calcium score not being all bad. Hook it up on YouTube or check it out on my podcast station. Our cash is completely right. And I've been caught discussing this with sports, other sports cardiologists at conferences talking about what a raised calcium score means. But it's it really speaks to the importance of having someone who's familiar with that space.
[24:03] talking Akash. I really do appreciate it. If you've got any final words for
[24:10] Um...
[24:12] anyone in that mindset where they want to be undertaking some exercise that might be new to them, what would be your advice? How would you tell them to be cautious about their own heart-related issues before they
[24:26] take off on their New Year's resolution for 2026.
[24:32] Yeah, I think, you know, I would say exercise is beneficial almost universally to all patients, but we want to do it the right way. So, you know, you want to listen to your body. You know, if you're experiencing symptoms such as exertional chest pain or, you know, shortness of breath, that seems to you a little bit out of proportion of just being out of shape. You know, these are things to bring up to your cardiologist.
[25:02] even those with significant heart disease or structural heart disease, with the few exceptions, exercise has tremendous benefits to overall mortality, cardiovascular mortality, as well as, you know, psychological well-being. So, you know, we would encourage everyone to exercise. And then, you know, if you're having symptoms with exercise, don't hide it, especially the athletes. That's something we commonly see people hide symptoms. And with sports cardiologists,
[25:32] and help you return to sports as soon as possible, safe to do so. So we're hoping in towards moving away from this paternalistic, telling people not what to do, towards more of a shared decision-making and a vision towards achieving common goals that athletes and patients are more open with their symptoms with us too.
[25:52] Thank you.
[25:53] Kash, thank you so much.
[25:55] Absolute pleasure to share a conversation around such an important and interesting issue. For those listening, Akash really is a leader in this space, and I'm incredibly privileged to have him share with us today. If you have any queries or questions, drop me a note at info at drWarrickbishop.online. If you've got any suggestions for a future podcast, let me know. Otherwise, as always, I really appreciate that you've given me your time to listen to this.
[26:25] as well as possible.
[26:27] For as long as possible, take care and bye for now.
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