
How Pushing to Extremes Led an Amateur Cyclist to Ventricular Tachycardia - bootload
https://cyclingtips.com/2017/04/book-excerpt-pushing-extremes-led-amateur-cyclist-ventricular-tachycardia/
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justinstephen
VT, sudden cardiac arrest and cardiomyopathy survivor here. I also have an ICD
(Implantable Cardioverter Defibrillator) like the subject in the article. From
a technological standpoint it's an incredibly interesting thing. On one hand I
have this fantastic piece of implanted technology that has on different
occasions saved my life. It has a 10 year battery life, supports wireless
communication and at regular check ins provides a wealth of data to the
electrophysiologist about ongoing heart activity (I'd love to have my own API
with at least read access to the device).

On the other hand he does a great job describing the PTSD the accompanies the
torture and pain the device can deliver. There's something psychologically
unique to the fact that this device is embedded inside you, capable of
delivering a horrific blow enough to knock you off your feet at a moments
notice. From a PTSD standpoint it's as if your assailant is always with you,
but permanently implanted within. You can't ever escape it, there's no
opportunity to remove yourself from the environment or the factors causing the
PTSD. You have to learn to come to grips with that, I've found that makes the
recovery much more complicated.

Beyond that, glad to see the cardiac risks of extreme athletics start to get
some public attention. There is a certain pull in extreme athletic circles to
chase numbers, a sort of oneupmanship to push the limits of what the human
body is capable of. Unfortunately at times it's not pretty when some find
exactly what those limits are.

Edit: To give it some perspective, I was 31 years old when I had my device
implanted.

~~~
paddedsmokes
I started to understand the realities of potential PTSD with a particular
patient. When I was a resident, we admitted a guy whose ICD started firing
while he was feeling fine and mowing his lawn. He freaked out, stripped his
shirt off and ran screaming up his neighborhood street until he found some
help.

He told the story in an almost comical way, and I nearly started giggling
because of how I imagined this would seem to an onlooker. But I quickly
realized how absolutely fucking terrified he would feel. I don't think I can
fully grasp the long-term emotional impact this might have on somebody who
forever knows they've always got that thing in their chest and that it's
statistically the most likely way they'll exit he world.

Seems you have some idea of how to cope with that, but I bet a lot of people
don't have those facilities.

~~~
JshWright
> I started to understand the realities of potential PTSD with a particular
> patient. When I was a resident, we admitted a guy whose ICD started firing
> while he was feeling fine and mowing his lawn. He freaked out, stripped his
> shirt off and ran screaming up his neighborhood street until he found some
> help.

My _first_ priority (in the back of an ambulance) with someone who had an AICD
fire is to get some significant sedation on board. I've seen multiple patients
where the the anxiety of anticipating another discharge is amping up their SNS
enough trigger their arrhythmia (triggering another shock).

~~~
brianwawok
Should they have a Bluetooth connection to my phone to allow shutting off the
stupid thing?

~~~
JshWright
No, for a variety of reasons...

For starters, there _are_ ways to disable it externally, but they use a fairly
specialized magnet. Secondly, even if they could shut it off, the patient
isn't really in a position to know if it's shocking them for a legitimate
reason or not. Shutting it off may simply shut their heart off...

Finally, the security properties of Bluetooth aren't exactly up to the
standards I would like to see for a "can deliver a fatal shock to someone's
heart" type device.

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ixnu
Many "recreational" athletes push themselves harder than olympic competitors.
Their bottleneck is talent and they attempt to overcome this with drive and
determination often against others with similar attributes. Many sink into
unhealthy habits in an attempt to just hang on to a weekend group ride or to
qualify for Boston.

I was shocked to learn that many weekend warrior friends have sophisticated
doping regimes just to stay competitive on group rides. I'm not sure there is
an answer.

~~~
InclinedPlane
The answer is obviously to be less competitive. Relax, you don't have to "win"
everything, just do your best and enjoy the experience.

~~~
projektir
The way society is currently set up, this answer doesn't make much sense. Look
everywhere you see, competitiveness and drive is encouraged, top athletes are
worshiped and paid zounds of money, and the importance of genetics is quickly
swept under the rug.

It doesn't really make sense to tell people to be less competitive when pretty
much everyone and everything else tells them to be more so.

~~~
eludwig
I understand what you are saying, but we need to remember one thing: it was
all recreational! Good God, the man wasn't being chased by killers, he was
doing this for fun!

The fact is, I don't care who you are, there are limits imposed on the 50 year
old body. There just are. If you want to keep active, that's great, but what
ever happened to being reasonable? Why is everyone in such a rush all the time
to have more fun faster and harder than anyone else?

Maybe this is an artifact of civilization? Since we are no longer being chased
by tigers we need to "fun" ourselves to death. Who knows.

To be fair, the article makes it clear that he never felt like he was
"pushing" too hard before the incident. It may be he didn't notice his body
talking to him, or maybe it just didn't until it was too late, which sucks.
Everyone is different. I can tell you that I'm over 50 and have definitely
noticed the effort and recovery challenges that accompany my age. I'm active
and love to run, bike, etc. But it certainly feels different than it did when
I was 15. I have to be reasonable about how much I do how fast.

Be reasonable, people.

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PhasmaFelis
Question. It seems like V-tach is not something that overwhelms you in an
instant--the first time, Endicott was able to stand for at least several
minutes, and it took him several hours after that to reach medical attention.
He would have died without it, but there was some time.

So why does the ICD strike without warning? Falling over unexpectedly is
pretty dangerous even if you're just standing or walking, and can easily be
crippling or deadly if you're older, as I imagine many patients are. Wouldn't
it be a lot safer if it gave you some kind of warning so you can stop and sit
down before the big jolt--a mechanical nudge or tiny tickle of current to some
heart-adjacent tissue?

~~~
Herodotus38
There is a slight warning, about 5 seconds where you can hear a "whining"
sound as the device charges up. It's not very loud though I've heard it being
in the same room as patients. I could see it being missed if you were doing
something loud/active.

The reason there isn't more warning is that you want to shock VT before it
degenerates into ventricular fibrillation, which is much more serious.

Your question about falls is a good one and it comes down to how much of a
trade off you strike with risks of VT/VF vs risks of the shock.

~~~
Cthulhu_
Couldn't they make it so it starts beeping alarmingly before triggering?
Giving you a few seconds to e.g. pull over, sit down, assume a fetal position,
etc. Or would that cause sudden stress and make it worse?

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maj0rhn
Am surprised the article did not mention two genes that are known to link
catecholamines (adrenaline et al) and ventricular tachycardia. One gene is for
the cardiac ryanodine receptor, and the other is for the CAS2Q gene.

An obvious conclusion is that the threshold for exercise-induced VT is
variable across individuals.

There are lots of other genes linked to sudden death during exercise.
Examples: long QT genes, hypertrophic cardiomyopathy genes. It's not hard to
understand why they are rare. :-)

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WalterBright
Once in college I decided to see how hard I could run around the track. I
finished the lap, but my heart was racing like mad and my vision was fading in
and out. I just laid down on the ground for a while, and nothing bad happened.

I decided that was a monumentally stupid thing to do and never did it again. I
jog regularly, but never push it past a modest point.

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mtw
Fortunately we have common tools to measure stress and recovery rate (HRV in
garmin or polar watches). And the latest ones don't even need a chest heart
rate strap. Go hard and fast when you train, make sure you get at least 2 days
of rest per week and most importantly get good sleep and rest. In case of
doubt , check HRV indicators

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nradov
I've been shopping for one of those devices and the latest reviews report that
wrist heart rate sensors aren't very accurate under hard exertion. And there's
no scientific evidence that HRV as measured by those devices is correlated
with the risk of a cardiac event.

~~~
Johnny555
I've been pretty happy with my Garmin Vivoactive HR for cycling -- I too was
worried that it would be wildly inaccurate, so I did a few rides with both the
Garmin (using its wrist sensor) and my old Polar watch with a chest strap to
compare them. They were very close to each other -- both on the bike looking
at live readings and later looking at the charts at home.

However, it could see it having less accuracy with an activity with more arm
motion, like running. And I have no evidence that my Polar sensor was very
accurate itself.

~~~
kqr
Yes, the primary concern with optical wrist sensors is "cadence lock", which
is when they start measuring the wiggle of the arm rather than the beating of
the heart.

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URSpider94
There's an interesting tie-in to the start-up world here. A co-worker of mine
started saying a couple of years ago that "cycling is the new golf," and
that's definitely true in Silicon Valley. You are more likely to run into tech
CEO's and bankers on Saturday morning climbing up 84 in Woodside than you are
at the driving range. And, if you want to be able to hobnob with those folks,
you'd better be able to hang with them as you pedal up a 10% grade ...

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Jotra7
Addictions are sad.

~~~
infinitelurker
..but some are better than others, and having that personality trait isn't
necessarily a choice

~~~
Baeocystin
Better in terms of less immediately destructive, sure. But I've gone to more
funerals from deaths of adrenaline junkies than drug ones. The holes they
leave when they're gone are the same.

~~~
kqr
The number of funerals you have attended could be a poor proxy for the number
of lives lost. Drug junkies tend to have fewer friends and be less vocal about
their addictions because society, culture and laws.

~~~
Baeocystin
Quite possible. I am not claiming ultimate truth.

But in my 43+ years of living, I've known enough of all of the above to come
to think that the specific what of addiction matters less than the core
pathology itself. The patterns are too similar across the board.

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sdadasrty
"He was an independent sales representative"

...

“For years it was like the hints were there in all the studies, and
[researchers] always conclude that more research needs to be done. And they’re
still saying that" ... "I’ve done the research, folks. It happened to me. I’ve
had friends that are either dead or alive that it happened to. [Trust me.]"

No.

~~~
URSpider94
I don't think you are being fair. It's pretty clear that he means secondary,
not primary, research, i.e reading papers and talking to experts. And, it's
quite common in medicine that there is very little communication or consensus
on the diagnosis and treatment of conditions like this, where five different
specialists could give you five different answers. Just look at how long it
took him to find someone to do the ablation treatment that gave him some
improvement.

