Is heavy physical activity a major trigger of death by sudden cardiac arrest? Not in Oregon

The idea that heavy physical activity is a main trigger of heart attacks is widespread. Often endurance running and cardio-type activities are singled out. Some people refer to this as “death by running”.

Good cardiology textbooks, such as the Mayo Clinic Cardiology, tend to give us a more complex and complete picture. So do medical research articles that report on studies of heart attacks based on comprehensive surveys.

Reddy and colleagues (2009) studied sudden cardiac arrest events followed by death from 2002 to 2005 in Multnomah County in Oregon. This study was part of the ongoing Oregon Sudden Unexpected Death Study. Multnomah County has an area of 435 square miles, and had a population of over 677 thousand at the time of the study. The full reference to the article and a link to a full-text version are at the end of this post.

The researchers grouped deaths by sudden cardiac arrests (SCAs) according to the main type of activity being performed before the event. Below is how the authors defined the activities, quoted verbatim from the article. MET is a measure of the amount of energy spent in the activity; one MET is the amount of energy spent by a person sitting quietly.

- Sleep (MET 0.9): subjects who were sleeping when they sustained SCA.
- Light activity (MET 1.0–3.4): included bathing, dressing, cooking, cleaning, feeding, household walking and driving.
- Moderate activity (MET 3.5–5.9): included walking for exercise, mowing lawn, gardening, working in the yard, dancing.
- Heavy activity (MET score ≥6): included sports such as tennis, running, jogging, treadmill, skiing, biking.
- Sexual activity (MET score 1.3): included acts of sexual intercourse.

What did they find? Not what many people would expect.

The vast majority of the people dying of sudden cardiac arrest were doing things that fit the “light activity” group above prior to their death. This applies to both genders. The figure below (click to enlarge) shows the percentages of men and women who died from sudden cardiac arrest, grouped by activity type.

Sudden cardiac arrests were also categorized as witnessed or un-witnessed. For witnessed, someone saw them happening. For un-witnessed, the person was seen alive, and within 24 hours had died. So the data for witnessed sudden cardiac arrests is a bit more reliable. The table below displays the distribution of mean age, gender and known coronary artery disease (CAD) in those with witnessed sudden cardiac arrest.

Look at the bottom row, showing those with known coronary artery disease. Again, light activity is the main trigger. Sleep comes second. The numbers within parentheses refer to percentages within each activity group. Those percentages are not very helpful in the identification of the most important triggers, although they do suggest that coronary artery disease is a major risk factor. For example, among those who died from sudden cardiac arrest while having sex, 57 percent had known coronary artery disease. For light activity, 36 percent had known coronary artery disease.

As a caveat, it is worth noting that heavy activity appears to be more of a trigger in younger individuals than in older ones. This may simply reflect the patterns of activities at different ages. However, this does not seem to properly account for the large differences observed in triggers; the standard deviation for age in the heavy activity group was large enough to include plenty of seniors. Still, it would have been nice to see a multivariate analysis controlling for various effects, including age.

So what is going on here?

The authors give us a hint. The real culprit may be bottled up emotional stress and sleep disorders; the latter may be caused by stress, as well as by obesity and other related problems. They have some data that points in those directions. That makes some sense.

We humans have evolved “fight-or-flight” mechanisms that involve large hormonal discharges in response to stressors. Our ancestors needed those. For example, they needed those to either fight or run for their lives in response to animal attacks.

Modern humans experience too many stressors while sitting down, as in stressful car commutes and nasty online interactions. The stresses cause “fight-or-flight” hormonal discharges, but are followed by neither “fight” nor “flight” in most cases. This cannot be very good for us.

Death by running!? More like death by not running!

Reference:

Reddy, P.R., Reinier, K., Singh, T., Mariani, R., Gunson, K., Jui, J., & Chugh, S.S. (2009). Physical activity as a trigger of sudden cardiac arrest: The Oregon Sudden Unexpected Death Study. International Journal of Cardiology, 131(3), 345–349.

Cortisol response to stress is much more elevated with ingestion of glucose than with protein or fat

Cortisol is a hormone that does a number of different things; a jack of all trades among hormones, so to speak. It tells the liver to produce glucose, preventing hypoglycemia. It also tells the liver to synthesize glycogen, which is in some ways the opposite of producing glucose. It tells the stomach to secret gastric acid. It is an anti-diuretic hormone. It suppresses the immune system, which is why it is frequently used to reduce inflammation, and treat allergies and various autoimmune diseases. It jump-starts an increase in free fatty acids in circulation, thus helping provide an important source of energy for endurance exercise.

Cortisol, together with epinephrine (a.k.a. adrenaline), even contributes to the creation of surprise-induced memories. It is because of this action of cortisol that Americans reading this post, especially those who lived in the East Coast in 2001, remember vividly where they were, what they were doing, and who they were with, when they first heard about the September 11, 2001 Attacks. I was living in Philadelphia at the time, and I remember those details very vividly, even though the Attacks happened almost 10 years ago. That is one of the fascinating things that cortisol does; it instantaneously turns short-term contextual memories temporally associated with a surprise event (i.e., a few minutes before and after the event) into long-term memories.

Similarly to insulin, you don’t want cortisol levels to be more elevated than they should naturally be. Natural levels being those experienced by our hominid ancestors on a regular basis. You need cortisol, but you don’t need too much of it. Many tissues in the body become resistant to hormones that are more elevated than they should be, like insulin and leptin, and this is also true for cortisol. It is a bit like people constantly shouting in your ears; after a while you cover your ears, or they get damaged, so people have to shout louder. If you frequently have acute elevations of cortisol levels, they may become chronically elevated due to cortisol resistance.

Chronically elevated cortisol levels are associated with the metabolic syndrome, the hallmark of the degenerative diseases of civilization.

Stress causes elevated cortisol levels. And those levels are significantly elevated if you consume foods that lead to a high blood glucose response after a meal. That is what an interesting experimental study by Gonzalez-Bono and colleagues (2002) suggests. The full reference and link to the study are at the end of this post. They used glucose, but we can reasonably conclude based on glucose metabolism research that foods rich in refined carbohydrates and sugars would have a very similar effect. If we think about the typical American breakfast, possibly even a stronger effect.

In order to do their study they needed to put the participants under stress. To cause stress the researchers did what many college professors have their students do at the end of the semester, which is also something that trial lawyers and preachers are good at, and something that most people hate doing. You guessed it. The researchers had their subjects do, essentially, some public speaking. The experimental task they used was a variation of the “Trier Social Stress Test” (TSST). The researchers asked the participants to conduct a 5-minute speech task and a 5-minute mental arithmetic task in front of an audience.

The participants were 37 healthy men who fasted for at least 8 h prior to the study. They were randomly assigned to one of four groups. The glucose group consumed 75 g of glucose dissolved in water. The fat group consumed 200 g of avocado. The protein group drank 83 g of proteins dissolved in water. The fourth group, the water group, drank plain water.

From a real world perspective, the fat and protein groups, unlike the glucose group, were arguably overloaded with their respective nutrients. Many people would not normally consume that much fat or protein in one single meal. This makes the results even more interesting, because it seems that fat and protein lead to virtually the same response as water, regardless of the amount ingested. The table below shows the cortisol responses for all groups.

As you can see, the cortisol response for the glucose group is a lot more elevated. How much more elevated? In the inner square at the top-left part of the figure you have the areas under the curve (AUC), which are essentially the estimates of the integrals of the cortisol curves for each of the groups. Usually AUC is a key measure when one looks at the potential negative impact of the elevated levels of a substance in the blood. Note that the cortisol AUC for the glucose group is much larger, about two times larger, than the cortisol AUCs for the other groups.

When one has a morning car commute, what is going to happen? Typically cortisol levels will be elevated, unless the commute is uneventful and done completely on “automatic pilot”; which is not very common, as people cut off in front of each other, make irritating mistakes etc.

What if, before that commute, one eats a “solid” breakfast with plenty of “healthy” sugary cereal covered with honey, a glass of “healthy” low-fat milk (of course, because fat “raises bad cholesterol”), and maybe three pancakes covered with syrup?

Cortisol levels will be much more elevated.

Doing this often, maybe after several years a person will become eligible for death by sudden cardiac arrest while doing some light activity.

Reference:

Gonzalez-Bono, E., Rohleder, N., Hellhammer, D.H., Salvador, A., & Kirschbaum, C. (2002). Glucose but Not Protein or Fat Load Amplifies the Cortisol Response to Psychosocial Stress. Hormones and Behavior, 41(3), 328–333.