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We dive into the intriguing world of endurance exercise and cardiovascular health with our guest, John C. Hagan III, an ophthalmologist and veteran endurance athlete. John shares his personal journey with long-distance running and the unexpected health challenges he encountered. We explore the latest research on the potential risks of excessive endurance exercise, the evolving medical perspectives on physical activity, and how Type-A personalities, common in the medical field, can find a healthier balance. Learn about the coronary artery calcium score (CACS), the concept of the “Goldilocks Zone” for exercise, and practical advice for maintaining cardiovascular health.

John C. Hagan III is an ophthalmologist.

He discusses the KevinMD article, “From marathons to moderation: Rethinking endurance exercise.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back John C. Hagan III. He’s an ophthalmologist, and today’s KevinMD article is “From marathons to moderation: Rethinking endurance exercise.” John, welcome back to the show.

John C. Hagan III: Thank you, Kevin. It’s a pleasure to be here.

Kevin Pho: So John’s been on in the past. Go to KevinMD.com/podcast to hear his story and his prior episode. But today let’s jump right into your most recent article, “From marathons to moderation: Rethinking endurance exercise.” For those of you who didn’t get a chance to read this article, what’s it about?

John C. Hagan III: I have been a marathoner since 1969, and I have exercised since childhood, and I have had a lifelong commitment to good health. And I’ve never voluntarily done anything that I thought was unhealthy, so no smoking, no drinking, diet. It’s hard to believe that I was young once. I’m closer to 81 than I am to 80.

But in the early 50s, which was my early childhood, exercise was bad. And I might add parenthetically at this point, if you follow the science, eventually you’re going to go over the cliff unless you have an open mind. So I have lived through exercise is bad, exercise is good, a lot of exercise is even better, to the point where exercise hurts your heart. And you know, same way, when I was young smoking was OK, made you look cool, and coffee was bad, give you a heart attack. And so we have to have an open mind to how things change.

So in 1969 I was a senior medical student at Loyola University in Chicago, and Ken Cooper came out with Aerobics, and I was just blown away by that. And I decided that the way I would keep my heart and my arteries healthy was by running.

And again, to look backwards, in the 50s heart disease was attributed to working too hard. When I was young there was episodic deaths in males in their 40s from myocardial disease. I mean, I can remember two classmates in high school that their dad just dropped dead, and it was ascribed to working too hard. And you know, he’s working too hard, it caused the heart attack. You know, people have a heart attack, they send him to bed. Ladies have a baby, send them to bed. You know, rest was the thing. And the idea that exercise might be good for you, and that not exercising was bad for you, was a totally new paradigm.

So many of us physicians are overachievers, and my motto has always been, too much is not enough. So I started marathoning, running, and continued that for a long, long time, through my internship, my residency, my time in the Air Force. And then in 1975, when I came to Kansas City to practice ophthalmology, I was a first-year subscriber to Runner’s World. I belonged to an organization called the American Medical Joggers Association, and the Grand Poobah of the American Medical Joggers Association was Tom Bassler. He was a pathologist, and the Bassler hypothesis was that anyone that could run a marathon, it would prevent ever having myocardial infarct or coronary artery disease. And I believed that, so I ran and ran and ran and ran.

And as a physician I thought, I need to have some scientific background for this. So the movement from exercise is bad to exercise is good, there are three individuals that really have contributed the most. One was Jeremy Morris, and he’s a Scottish physiologist, and he did a brilliant study from about 48 to 52 in which he studied London bus drivers. And these are two-story conveyances, and they have a driver who sits the whole shift and drives, and then they have a conductor that’s constantly moving, never sits down, and is climbing up to the second floor. And he followed these individuals to see if there was a difference in their cardiovascular health, and by far the group that was healthiest were the ones that moved the most.

And then Jeremiah Stamler, who was a cardiologist, actually was in Chicago the same time that I was at Loyola. He looked at the same data, conducted his own data, and he was the individual that came up with risk factors, and one of the risk factors was lack of exercise. So we got a 180-degree turn.

And then there was my personal muse, and that was Ken Cooper, and I read his book. And to Dr. Cooper’s credit, he never recommended hyper exercise, he recommended moderation. But again, with my too much is not enough, I took off.

So over the next 20, 25 years I ran about 30 half marathons, four marathons, a dozen or more short triathlons, two half Ironman triathlons, just the whole deal. And at this point I was pretty smug. I thought, you know, my gosh, I built a heart that’s just invincible, I’m going to live to be 100 and I’m not going to die of disease.

And when I was in my early 60s I was taking a shower and I noticed my pulse was doing something crazy, never done this before. So I checked my pulse and it was irregularly irregular. And although I’m an ophthalmologist, I remember enough from medical school, saying, oh my God, I’m in atrial fibrillation. So I went to the hospital and the cardiology group there confirmed the diagnosis. They did a complete workup, and I had what at that time was called lone atrial fibrillation, which is AFib in the lack of coronary artery disease. They basically did not tell me to modify my exercise.

But I started reading on my own, and again, I’ve had a Runner’s World subscription since about 1967, and there started to be deaths and heart disease among marathoners. Jim Fixx wrote a book which was widely read, and he died while running. Alberto Salazar, who was an internationally famous long-distance runner, had a cardiac arrest while running and was reportedly clinically dead for 14 minutes. And a number of people developed coronary artery disease and needed bypasses.

And one of the things they were espousing in terms of technology, and this was not in the medical journals, this was in Runner’s World, was a coronary artery calcium score done by CT. So I asked my cardiologist at that time about that test, and they said, nah, we don’t need it, it won’t show us anything we don’t know, it’s an expensive test, there’s radiation, just, you know, essentially forget about it. And I’m a pretty compliant person, so I did, but I was pretty uncomfortable.

And then something very fortuitous happened, that was my insurance changed. I had to get a new cardiologist.

Kevin Pho: Sure.

John C. Hagan III: So I looked around, and an internationally known preventive cardiologist here in Kansas City is James O’Keefe, and he is widely published, widely known, and fortunately I could get on his schedule. So I went in and I told him my tale of woe about atrial fibrillation and so forth, and then I asked him about getting the coronary artery calcium score. And he said, that’s a great idea, I was going to recommend it myself.

So if there’s ever any test that I thought I was going to ace, it was that one. So I had the test, I went home, they told me they’d have the results in a few days. And about two hours after I had the test done, Dr. O’Keefe’s office called me and said, can you have your wife drive you to the office immediately?

Probably most of you know, but a normal coronary artery calcium score is zero, and if it’s less than 100 you can probably live with that. Mine was 1,606.

Kevin Pho: Wow. And yeah, that’s kind of over the top. And the calcium is a surrogate for atherosclerosis, so plaque burden essentially.

John C. Hagan III: So this indicated right off coronary artery disease. So then I had an even more extensive workup, and that also was normal, my lipids were good. Nevertheless, they put me on statins.

And one of the things that I’ve done for the last 23 years is I’m the editor of Missouri Medicine medical journal. And about the time this was all going on, we got an article from Dr. Schwartz in Minneapolis that belongs to a cardiology group there, and they had looked at a large number of senior runners and compared them with non-runners with similar cardiovascular risk factors, and identified that the running group, like myself, had elevated coronary artery calcium scores.

So with the idea that, how could I spend all this time running and have an artery that’s full of stone, I consulted with Dr. O’Keefe. He said, yeah, that’s the way things are going. And so just prior to the Boston Marathon in 2014, Missouri Medicine published a full set of articles outlining the research that showed this increased coronary artery calcium. And the running world went wild. I mean, I didn’t get death threats, but they told me, you know, what is it with you, what is it with your medical journal, you know, a medical journal in flyover country, how could you possibly do this? I was called by a cardiologist from Harvard, I won’t say his name, but he essentially read me the riot act.

So what has happened since then is that the subsequent literature done all over the world has validated this, and also validated that hyper exercisers, and I’m talking about people that go out and pedal to the metal for over an hour, especially those over 40, have an increased incidence of atrial fibrillation and coronary artery calcium score.

Now the question at that time was, if I, who basically try and take care of myself, have a coronary artery score of 1,606, and you compare it to the typical cardiovascular patient, hypertensive, smoking, overweight, bad diet, is the risk factor the same? And the answer is no. The runners, the hyper exercisers, the people that lead good diets and good lifestyle, the risk is much, much lower.

And the question came, why is that? And what has been found is that the plaque in runners like myself, they have a high calcium density, they’re fibrotic, they’re low lipid, the endothelium is fairly rigorous, and they do not appear to be very prone to causing thrombosis in coronary arteries. OK, the typical patient that most of your viewers know, with multiple risk factors, of course their atheromas are high lipid, fatty, and easily thrombosed.

So that gives me some peace of mind. But if I could go back and know what we know now about exercise, hyper exercise, I would be a 10K runner.

And as preparation for this I’ve been doing literature search, and there’s lots and lots of literature that has substantiated what I’ve just reviewed. However, there are cardiologists in some studies that make the point that hyper exercisers live longer than the average. Now, that is not a good study. A better study would be, do hyper exercisers live longer and better than mild exercisers, like someone that runs a 10K or a six mile? And I could not find that study. I don’t think it’s been done.

So my advice to anyone that’s interested is, live a healthy lifestyle. Exercise is one of the most important things to keep yourself healthy, but do it in moderation. You know, if you have to do a marathon, build up to it, do the marathon, take that off your bucket list, and then drop back to an easy 10K, or you know, moderate running. I think that’s by far the healthiest thing to do.

Kevin Pho: Sure. So when you say hyper exercise, what is the definition for that? What category of exercisers does this affect, these elevated coronary calcium scores?

John C. Hagan III: Well, there’s no hard and fast definition, but basically what we’re talking about is all out exercise for an hour or more. Now, you know, when you run a marathon you’re out there four to five hours. And you know, I’ve done half Ironman and I was out there for like nine hours, eight hours. So you can get all the benefits of exercise by exercising moderately for 30 to 45 minutes, and you’ll have a lot more time for your practice or your family or your kids or, you know, whatever you want to do. I think it’s a smart thing to do.

Kevin Pho: So for those who quote unquote hyper exercise, should they be worried about their coronary artery calcium score? Should they be getting these scans to see what that number is?

John C. Hagan III: Well, obviously Jim Fixx would, obviously Alberto Salazar would. So being an elite athlete doesn’t shield you from coronary artery disease or sudden cardiac death. So I would say yes. I would say first of all the smart thing is just don’t do it, you know, do your long distance and then drop back. But if you’ve been a hyper exerciser and you plan on doing it, I would certainly recommend that you have a coronary artery calcium score, and of course check all your other cardiac parameters, you know, stress tests and so forth.

Kevin Pho: So in terms of the current thinking among the marathon community, is this as far as you can tell a concern for them? Are there guidelines perhaps looking for elevated coronary artery calcium score in this subgroup, or is this something that is not quite in the mainstream yet?

John C. Hagan III: No, it’s definitely in the mainstream. And one other thing I forgot to mention, I’d just like to introduce a parenthetical, and I’ve spoken to Dr. Cooper about this. One of the concerns of people that look into this is running your immune system down. And there have been some very, very, very world-class athletes, marathon runners like Grete Waitz, that have died of cancer, as well as Fred Lebow, who was head of the New York City Marathon. And here in Kansas City our prime female marathoner also died of cancer. So that’s another reason.

But to get back to your question, yes, the marathon community is very aware of this, and most of them have come over. Now you have to realize that there’s a whole industry out there of sports apparel, shoes and so forth like that. This threatens their livelihood, so you’re not going to find Nike or some of these other ones proposing that.

The other thing, I won’t mention the name, but for the last ten years I have been in contact by email with a several time winner of the Boston Marathon. I mean, just a legend. And he also has an elevated coronary artery score, not quite as high as mine, is like 900 something like that. And he has chosen to continue to run marathon distances. He runs in Boston every year, and he’s done OK so far. But there are runners that haven’t done so well.

Kevin Pho: We’re talking to John C. Hagan III. He’s an ophthalmologist. Today’s KevinMD article is “From marathons to moderation: Rethinking endurance exercise.” John, as always, we’ll end with some of your take-home messages that you’d like to leave with the KevinMD audience.

John C. Hagan III: Well, have an open mind, and this applies to everything in medicine. And realize that exercise done properly, in moderation, is one of the most important keystones of remaining healthy. But you can do too much.

Just to get back to marathons for a moment, one of the big risk factors initially was getting dehydrated, so people were told to drink as much water as possible while they ran marathons. Well, then people started dying of water intoxication, you know, dilutional hyponatremia. So everything in moderation. You know, exercise, you’re going to run, keep it easy. If you have to do a marathon, do it, get it off the list, and then drop back.

Kevin Pho: John, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

John C. Hagan III: Thank you, Kevin. I enjoyed being here. Thank you.