Category Archives: My Articles

Screening athletes for heart problems: More harm than good?

Check your blood pressure and pulse to prevent heart problems

Advocates of screening athletes for cardiac conditions claim that “screening saves lives”. Research is showing that this approach may actually be flawed, and that screening might be doing more harm than good. I tend to agree.

An article in the Guardian by Nicola Davis (April 2016) summarises very nicely the inadequacies with pre-participation screening programs for athletes and the research gaps that sit behind them. Davis draws on the work of a group of Belgian researchers, published in the British Medical Journal, Harms and benefits of screening young people to prevent sudden cardiac death.

Current practices

Pre-participation screening for competitive athletes is acceptable practice in some countries and is recommended by a number of sports organisations and governing bodies, including the International Olympic Committee. Screening can entail an assessment of personal and family history, physical examinations and/or electrocardiograms (ECGs).

Italy has been paving the way for mandatory pre-participation screening for young non-elite athletes since the late 1970s, with a seminal paper in 2006 purporting its benefits. Today, Italians are not eligible for competitive sports until their cardiovascular health has been confirmed. However, questions regarding the validity of the Italian study have been raised, and remain unanswered, as discussed by Dr Thompson in the highly regarded journal, Circulation. Interestingly, the Netherlands abandoned its mandatory screening program in 1984, due to “the poor diagnostic performance of screening tests”. Great Britain undertook screening of its elite Olympic athletes prior to the London Olympics, and while a couple of athletes were diagnosed ‘at risk’ apparently no one was excluded from competition. Free screening promotions targeting young people 14 to 18 years old are not uncommon in the United States and the United Kingdom, typically “looking for signs of hypertrophic cardiomyopathy, or HCM, an inherited condition that is the number-one cause of sudden death among young people under age 30”.

Problems with screening programs

Screening will increase the number of athletes falsely diagnosed with disease.

This can result in unnecessary medical treatment, disqualification from competition, and loss of contracts or sponsorship which will have lasting impacts on an athlete.

Screening will increase the number of athletes correctly diagnosed with real disease who may never be destined to experience a cardiac event.

Once doctors find abnormalities, they are obligated to perform additional tests and procedures, which may result in overly aggressive or inappropriate treatment. According to Nicola Davis, “An athlete would otherwise live a normal life if their cardiac disease is left undetected”, and can be put under considerable distress.

Disqualifying athletes simply on the basis of a diagnosis is inappropriate.

Assessing the risk of an adverse event occurring in an individual with cardiac illness and being able to tell whether they are likely to experience a cardiac arrest is not straightforward. Put simply, disqualification may not be the best remedy.

Most individuals with HCM do not die suddenly during physical activity.

No one really knows whether restricting exercise in an HCM patient improves their prognosis. In fact, exercise may have benefits for individuals with HCM, as for normal healthy athletes. British researchers have reported that athletes with HCM exhibit qualitatively similar physiological cardiac adaptation to normal healthy athletes.

A personal perspective

As an athlete with hypertrophic cardiomyopathy, I find the threat of disqualification from competition a real deterrent to screening and an unfair imposition on a person with a medical condition. I am a firm believer in the principle of Olympism (as outlined in the International Olympic Committee Charter) and I regard sport participation as the right of every individual. I don’t agree with recommendations that impose restrictions on sport participation for people like me with hypertrophic cardiomyopathy. I really think it should be up to the affected individuals to decide this, once fully informed and able to assess the risks for themselves.

My own diagnosis was not made through any screening process but prompted by presenting symptoms (a history of fainting). That said, although there are purportedly around 1% of young athletes with unrecognised or asymptomatic heart disease, I do not support the cardiac screening of athletes. While advocates for screening emphasise that “screening saves lives”, they don’t properly address the impact of a cardiac diagnosis on a young person.

Denver, Colorado, USA - April 27, 2008: Elite runners at the starting line of the Cherry Creek Sneak near Cherry Creek North Street in Denver, Colorado

Apart from the problems highlighted above, the following issues are also significant to a ‘diagnosis by screening’. Yet, they are rarely if ever discussed in the literature.

Personal health and life insurance

A positive test result for a “life-threatening medical condition” doesn’t give you much hope in the health insurance stakes (and don’t even think about qualifying for a life insurance policy).

I am grateful that at the time of my own diagnosis, I had existing health insurance and life insurance policies. Otherwise, after my diagnosis, I would have been ineligible. This matter of health insurance can be overlooked in fit young people.

I think it is terribly negligent of health care professionals and sports governing bodies to offer cardiac screening to individuals without flagging the implications of a positive result.

Psychological wellbeing

Athletes can experience significant emotional and mental wellbeing issues as a consequence of disqualification from sport, which invariably impacts their lifestyle and career choices. Sport participation can actually be better than no sport at all, even in the presence of a cardiac problem.

The athlete’s voice should count

” … making decisions affecting their future athletic careers through mandatory exclusion is paternalistic and such decisions are not rightfully within the domain of medicine.”

This is the real issue for me when it comes to screening — the athlete’s voice too often gets lost in discussions of diagnosis and intervention.

“There is a push for a system which involves screening and mandatory exclusion from sports participation of those at risk … while screening can provide useful information to at-risk athletes, making decisions affecting their future athletic careers through mandatory exclusion is paternalistic and such decisions are not rightfully within the domain of medicine.”  — Clearing House for Sport reporting on research published in the British Journal of Sports Medicine

I couldn’t agree more!

Pre-screening counselling

Pre-screening counselling on all of the above issues should be mandatory in the context of cardiac screening. Having a conversation with an athlete and getting him/her to consider the repercussions should screening flag a cardiac problem must be a critical part of the screening process. I believe it amounts to neglect if these issues are not touched upon when offering cardiac screening to athletes.

Recommendation

While there may be a time and a place for screening, I strongly urge any young person who is encouraged to undergo cardiac screening in the absence of symptoms to consider the impact of a cardiac diagnosis on your lifestyle and future sports participation.

Do give serious consideration to postponing screening until you have a valid health insurance policy in place.

Author: Kara Gilbert @ KMG Communications

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Running is not so bad on your knees, after all!

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I applaud studies that challenge the status quo, and make an effort to dispel ‘myths’ that have pervaded our culture to such an extent that they become regarded as the ‘norm’. I am also very sensitive to ‘scientific tradition’, which advocates a certain remedy, in spite of ‘personal experience’ that does not support the remedy. We are not all moulded out of the same stone.

How many times do you hear people bemoan running …

… as an activity not really so good for you? Such critics suggest that repetitive pounding destroys your joints and brings about all sorts of aches and pains. As someone who has spent most of my life running, I can’t say that I suffer this problem. After all these years, my joints still feel fabulous!

Benefits of exercise

There is so much evidence in the literature supporting the notion that exercise is one of the most effective ways to treat osteoarthritis because it:

  • Reduces pain;
  • Improves flexibility;
  • Strengthens the muscles supporting the joints; and
  • Promotes weight loss, which reduces the stress on your joints.

Yet, most of these proponents of exercise for osteoarthritis recommend non-weight bearing sports, such as swimming and stationary cycling, as beneficial for people with osteoarthritis.

‘New wave’ thinking

At last, there is evidence emerging to dispel these myths. It seems that people who don’t run suffer more joint pain than people who do run. Go figure!

Check out this interesting article by Alex Hutchinson, which gives us a new perspective on knee pain: Here’s More Evidence That Running Doesn’t Ruin Your Knees

I have always believed that running is a good thing!

Author: Kara Gilbert @ KMG Communications

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Exercising in the heat: How does hot weather affect you?

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It’s not simply the high temperature that affects your physical performance

Your body will show quite a complex physiological response to heart, and circumstances like chronic illness, medications, weather conditions, clothing and general physical form will affect your ability to adapt.

For more information about exercising in the heat and the implications this will have on your sport routine and performance, go to the Australian Fitness Academy to read my full article.

Author: Kara Gilbert @ KMG Communications

Endurance athletes and arrhythmias: Is there an association?

Runner-shaped blip on a medical heart monitor (ECG - electrocardiogram) with blue background and heart symbol.

The largest prospective study of athletes ever

The largest prospective study in the world is happening right here on our doorstep (that is, if you live in Melbourne) – and it is focussed on athletes and their hearts. In a recent article that appeared in Cycling Tips, Dr Andre La Gerche from the Baker Heart and Diabetic Institute provides some interesting perspectives on the investigations, which will see researchers follow athletes over a long period of time. This story has special significance for me. A synopsis follows:

Athlete’s heart

Many of you would be familiar with the notion of ‘athlete’s heart’, which is essentially an enlarged heart attributed to excessive training, often associated with elite endurance athletes. But, did you know that one of the undesirable effects of a large heart is the increased tendency to experience irregular heart rhythms?

Atrial fibrillation (AF)

The most common heart rhythm disorder in people of middle-age and older is ‘atrial fibrillation’ – a random firing of electrical signals from the upper chambers of the heart that causes a rapid and irregular heartbeat.

Some people with AF do not experience symptoms, and are completely unaware that they have AF. Others may suffer symptoms, including the uncomfortable sense of an irregular heart rhythm, fatigue or breathlessness.

Is too much exercise actually bad for you?

Research has shown that there is a higher rate of AF amongst endurance athletes compared with non-athletic individuals (although, interestingly, this excess in AF has not been observed in female athletes). This begs the controversial question:

‘Can too much exercise start to cancel out the health benefits of moderate exercise?’

Despite the growing trend that warns of the dangers of over-exercising, there is a paucity of evidence to know whether the heart changes seen in athletes might cause other potentially dangerous arrhythmias. Furthermore, as La Gerche emphasises, we do not have reliable predictive measures for determining which athletes might develop problems down the track.

Food for thought … !

As someone with an existing heart muscle disorder, viz. hypertrophic cardiomyopathy, I’m obviously very interested in this research. I have a thickening in my ventricular wall which means that I am already predisposed to having irregular heart rhythms, notably non-sustained ventricular tachycardia (VT). After my diagnosis at the age of 35, I decided to take up endurance training where I could keep my heart rate down within relatively ‘safe limits’. I am very careful to keep myself in check on the odd occasion when I might run in shorter and sharper races, and I am also cautious when climbing hills. I must be careful not to get my heart rate too high, as this might trigger a potentially dangerous heart rhythm or cause my ICD/internal defribillator to discharge unnecessarily.

Hence, the article by La Gerche raises questions for me. If ‘endurance’ training has its own set of unique side effects, then someone like me with hypertrophic cardiomyopathy might not actually be taking the ‘safe course’ by concentrating on endurance, even if that accommodates a lower heart rate for training and competitions (Of course, there are many who would recommend the safest bet for me is to stay idle and not exert myself, at all – somehow that falls outside my scope of comprehension.)

If there should be any causative relationship between endurance and heart arrhythmias, does this mean that my already irregular heart rhythm is likely to become especially more unpredictable should I persist with endurance training over time? Am I more susceptible than the average Joe? Definitely, food for thought … !

The Pro@Heart Study

Researchers in Australia, Belgium and France are collaborating together to investigate the association between endurance sport and arrhythmias. They will comprehensively assess young elite athletes and follow their health and performance for many years.

Some of you might have heard of the large scale prospective studies of the general population that have contributed to our understanding of the health effects of cholesterol, blood pressure and other lifestyle factors – notably, the Framingham Heart Study (New England, USA) and the Busselton Health Study (Western Australia).

There have not been studies of this nature and scale in athletes. The Pro@Heart Study aims to be the largest propective study in the world.

Watch this space! This body of work will surely yield the most comprehensive picture of athletes’ hearts that we have to date. I know that I certainly will be following this one over time.

Author: Kara Gilbert @ KMG Communications

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Rip Currents, Heart Health and Water Safety

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According to the Royal Life Saving Society of Australia’s ‘National Drowning Report 2015‘, 271 people drowned in Australian waterways in the period 2014/15.

  • Of the total drowning deaths, 216 were men and 55 were women
  • The 45-54 years age-group suffered the largest number of drowning deaths, with 48 drownings (18% of total drownings)
  • 55 (20%) of drowning deaths occurred at beaches.

Robert Brander is a coastal geomorphologist with expertise in rip currents and is also a member of the Tamarama Beach Surf Life Saving Club.  In a 2014 article for The Conversation, he states that 21 people drown each year in rip currents on Australian surf beaches.

Brandon writes: “This exceeds the long term annual average of fatalities caused by bush fires, floods, cyclones and sharks combined.” This suggests, interestingly, an attitude of ambivalence towards rip hazards in Australia compared to shark attacks and bushfires which receive significant media attention and government funding commitments for developing interventions. Perhaps, as Brandon argues,  this is motivated by the fact that “rip currents are always present and rarely result in more than one fatality at a time”.

‘Beach Safe’ Guidelines

Check out Surf Lifesaving Australia’s BeachSafe website. Here, you will find an excellent summary of rip currents, one of the best overviews I have come across. There are super diagrams and video clips illustrating the different types of rip currents – from fixed to flash to mega rips – along with tips on the tell-tale signs to watch out for before entering the water.

The University of New South Wales (UNSW) and Life Saving Australia are undertaking collaborative research to better understand the phenomena of rip currents, escape strategies and how to best educate people about them.

What is clear is that:

  • The calm area on the beach is not always the safest place for you to swim
  • Rip currents will not suck you out into the nethers of the deep, dark ocean

Rip Current Survival

Water behaviour can be unpredictable and the nature of rip currents can be quite different across geographic locations. Research has also shown that people’s experiences of rip currents vary considerably.  Brander therefore cautions: “No single message is suitable for advising people how to react or to escape when caught in a rip current.”  

A combination of floating, swimming and staying calm are key ingredients of any escape strategy.

Life Saving Australia’s current advice is as follows:

If you get caught in a rip current, you need to know your options:
1. For assistance, stay calm, float and raise an arm to attract attention.
2. While floating, rip currents may flow in a circular pattern and return you to an adjacent sandbar.
3. You may escape the rip current by swimming parallel to the beach, towards the breaking waves.
4. You should regularly assess your situation. If your response is ineffective, you may need to adopt an alternative such as staying calm, floating and raising an arm to attract attention.
Rip-Currents-Schematic-Cropped

Information and illustration from Beach Safe: http://www.beachsafe.org.au/surf-ed/ripcurrents

Science of the Surf

If you are keen to learn more about rips and water safety, I highly recommend the website, Science of the Surf (SoS) which was founded by Rob Brander.

An educational program for beach and surf safety, the aims of SOS are to reduce the number of drownings and injuries on our beaches.

The SoS rip current time lapse footage, with purple dye, is pretty spectacular.

Heart Health and Water safety

Another interesting fact emerged from the Royal Life Saving Society of Australia’s ‘National Drowning Report 2015’.  Of the people who drowned, 51 (19%) had an underlying medical condition and the pre-existing medical condition was found to have contributed towards the drowning in 36 of these cases (71%).  

The most common conditions were cardiac conditions (including hypertension, ischaemic heart disease, coronary artery atherosclerosis).

These stats, along with the fact that the 45-54 years age group was the most impacted by drowning deaths and that 89 (33%) of the total drowning deaths occurred in people aged 55 years and over in 2014/15, have Royal Life Saving issuing some clear recommendations.

Some of these recommendations are:

Know your limitations: Older people need to be aware of changes in personal fitness and skills in their older years, especially if they haven’t regularly maintained water-based activities.

Be aware of medical conditions: Have regular medical check-ups, as medical conditions and medications can affect your abilities in the water.

Avoid alcohol around water: This seems fairly obvious. Additionally, people in the older age groups are more likely than their younger counterparts to be on long-term medication and are often unaware of the detrimental effects of combining alcohol with their medications.

Ease your way back into aquatic activity:  Royal Life Saving Australia runs a Grey Medallion Program, which is a fabulous way to ease older people back into aquatic activity. Check it out!

Author: Kara Gilbert @ KMG Communications.com.au

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Age-Group Athletes: Have you been drug-tested yet?

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You might not be an elite athlete but you probably count yourself as a fairly competitive age-grouper. Did you know that Triathlon is breaking new ground in the war on drugs in sport? The world governing bodies in Triathlon are now targeting age-group competitors for drug testing, not simply elite athletes.

Regardless of your status as an elite or age-group athlete, if you are a member of a national governing body (e.g., Triathlon Australia), and/or compete in a World Anti-Doping Agency (WADA)-sanctioned event (e.g., Ironman), you can be tested for any substance on WADA’s prohibited list.

Triathlon Australia’s Anti-Doping Policy

In 2015, for the first time, Triathlon Australia (TA) conducted anti-doping testing on age group athletes at several events. This entailed taking blood and urine samples at the Mooloolaba Triathlon and the Ironman Asia Pacific Championships in Melbourne. The tests were in line with TA’s new Anti-Doping Policy, released on 1 January 2015. Many of you may not even realise that this document exists.

Drug testing in non-professional sports is not new; for example, the Australian Football League (AFL) has occasionally contracted Australian Sports Anti-Doping Authority (ASADA) to conduct tests at suburban football matches. With scandals over recent years in athletics, cycling and football, it seems likely that other sports will also get on board to examine their grass roots and explore strategies to develop the integrity of their sport cultures.

Unfortunately, points of uncertainty are likely to emerge for the non-professional (tri)athlete not familiar with drug-testing procedures or how even their own medication management could be breaching the rules.

WADA Prohibited List 2016

How familiar are you with WADA’s list of banned substances?  

I bet many age-group athletes are probably not aware that there are some fairly common medications included in the banned list of substances.

Some of the substances on the list include medications prescribed by doctors to treat not uncommon medical conditions, including asthma, diabetes and blood pressure. Such medications include:

  • Insulin
  • Beta-2 agonists (except therapeutic doses of salbutamol, formoterol and salmeterol)
  • Diuretics

Even some regular over-the-counter cold & flu medications now pose a risk for the competitive age-grouper. For example, the following chemicals, which are common ingredients of cold & flu treatments, are banned during competition:

  • Pseudophedrine
  • Levmetamfetamine

Therapeutic doses of prohibited substances may be acceptable but only if you have applied for a Therapeutic Use Exemption (TUE). For age group athletes, this can be done retrospectively. It will require supporting documentation from your treating doctor.

The overarching principle of the drug-testing policy is to look after the health of the athlete.

Familiarity with drug testing protocol actually helps raise awareness among athletes of the risks of training and racing while on ‘regular’ therapeutic medications. The risks of illicit substances such as anabolic steroids and stimulants are documented (refer to this 2010 research paper by Angell et al. in the British Journal of Sports Medicine for a good overview). The dangerous side effects of EPO/blood doping are well documents in cycling , and the sport recognises the impact this is having on amateur cyclists, too (refer to an article by Kathryn Dyle here).

In contrast, many athletes with common medical problems are ignorant of potential risks associated with exercising while on some medications. For example, beta blockers prescribed for hypertension or heart arrhythmias can impair your temperature regulation during prolonged exercise, predisposing you to dehydration and hyperthermia.

Making sense of policy

I think we are all fine with the intention of WADA and triathlon national sporting bodies to improve the integrity of the sport. However, the implementation of fairly new policy could see some age-group athletes found guilty of drug doping simply because they unwittingly are taking a banned substance, often for genuine therapeutic reasons.

While all athletes are expected to be familiar with the current code, the Anti-Doping Policy is a complex document, more a legal paper full of various “Articles”. It is a tedious read.

Ignorance is no excuse

Age-group athletes, be warned. Page 1 of the Anti-Doping Policy contains a clear warning to athletes and athlete support personnel. These items in the warning stand out:

  • You are responsible for knowing what the anti-doping rule violations are
  • You must find out which substances and methods are prohibited
  • Ignorance is no excuse

Unsure of where to get advice about your medications?

Get the phone App released by WADA. It lets you check the status of chemicals listed on a supplement or medication.

Access ‘Check your Substance’ service. Go to the ASADA website or call 1300 027 232

Talk to your treating doctor.

Additional information 

Formats for testing of age-group fields

According to Susan Lacke at Triathlon.com, a “top three and random” strategy is usually applied to the testing of age-group fields – podium finishers get automatically tested, then half a dozen or so more randomly selected athletes across the field.

“Out-of-competition’ (OOC) testing is generally focussed on elite athletes in the professional field. However, age-group athletes should also now be prepared to have a national sports anti-doping official representative arrive unannounced at their home.

Protocol for OOC testing of age group athletes is very clearly outlined in Triathlon Australia’s Integrity Framework document, which includes the following statements:

“Triathlon Australia will request ASADA [Australian Sports Anti-Doping Authority] to include up to 8 age group athletes in triathlon’s Domestic Testing Pool [DTP]. These athletes will be informed by ASADA of their inclusion in the DPT. Triathlon Australia will provide residential details of the age group athletes to ASADA.”

Author: Kara Gilbert @ KMG Communications

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Do you know how your medications work? Athletes and beta blockers.

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This article is motivated by some incidental conversations I’ve had with fellow athletes in recent times regarding dissatisfaction with their own medication regimes. The use of beta-blockers, in particular, for managing hypertension (high blood pressure) or arrhythmia (irregular heart beat) in athletes has cropped up a few times.

Here, I give an overview of beta blockers and set out some of the salient issues for athletes who are on beta-blockers. If this topic bears some relevance to you, then I hope this information will inspire healthy and constructive dialogue with your treating doctors.

Please remember, the information on this site isn’t intended as a substitute for professional medical advice.  Please consult your doctor for specific help with your own health.

 Athletes’ frustrations with beta blockers

Athletes’ personal experiences with beta blocker medications, across a range of sports, can be found in various forums across the internet. Some of these accounts by athletes may resonate with you:

Posted by insanedad, June 27, 2005, at Slowtwitch Triathlon Forum: “This may sound strange but in my races I did last year, I would always feel like my heart just couldn’t keep up with my body […] It was as if my heart hit a wall and would not allow me to go any faster.”

Posted by Phil K, August 23, 2013, at Runner’s World Forum: “The past six weeks I have had a series of very difficult training runs […] I started to have wild thoughts like ‘age was setting in’, and that ‘my time for crisp competitive running was over’. The sluggish workouts, the physical unresponsiveness, started to affect me psychologically …” 

Posted by slowmo, May, 2012, at Marathon Swimmers Forum: “You will have this feeling as though your arms and legs are really heavy [ … ] The drug acts like a throttle.”

Posted by Schwingding, June 27, 2005, at Slowtwitch Triathlon Forum: “I was like a limp noodle out there on the bike. I could go long distances at an easy pace just fine, but I just could not work at all at higher effort levels. It was like someone had put a rev limiter on me.”

Posted by Theo, April 2013, at Marathon Swimmers Forum: “I still experience the heavy arms and inability to swim the sets I want if I take the medicine prior to the workout.” 

What are beta blockers?

Beta blockers are drugs that regulate your heartbeat. They block the action of the hormone in your body called adrenaline (also known as ephinephrine). They do this by preventing the normal binding of adrenaline to so-called beta receptors on nerves in your arteries and heart muscle. Beta receptors control heart rate and the strength of its contractions, and influence blood pressure.

Taking beta blockers will cause your arteries to become wider (arterial dilation) and decrease your heart rate and strength of its contractions – these effects will lower your blood pressure. Put simply, your heart’s demand for oxygen and blood are reduced as your heart does not have to work as hard to pump blood throughout your body.

Some examples of beta blockers

There are a variety of beta blockers being prescribed today in clinical practice. They usually end in ‘olol’ or ‘alol’ on your medication lists, although there are a number of different brand names. Some examples are:

  • generic name           e.g., brand name
  • metoprolol                 e.g., Lopressor, Toprol, Betaloc
  • labetalol                     e.g., Normodyne, Trandate
  • carvedilol                   e.g., Coreg
  • propranolol                e.g., Inderal, Bedranol

Brands of beta blockers

Brands of beta blockers may have different availability and approval classifications in different countries, which can make looking them up on the internet quite challenging. I am aware that most of you accessing this page reside in Australia. If you wish to take a closer look at the different beta blockers, I recommend you access this resource “All about heart medicines” at Heart Research Australia, which is specific to medications available in Australia. Refer to the section on beta blockers. Of course, you should always consult with your doctor about your medication queries relating to your own heart health.

Selecting the right beta blocker

The choice of beta blocker depends on the medical condition being treated because beta blockers, although similar, differ in their action. For example, research cites  different actions, including duration of effect (3 hours to 22 hours), the types of beta receptors they block (β1-selective or β1/β2-nonselective), etc. Your doctor will take into account your medical condition and lifestyle factors when selecting a beta blocker most suitable for you.

What medical conditions are managed with beta blockers?

High blood pressure is the most common cardiovascular problem discovered in athletes, according to Dr Larry Cresswell at Athlete’s Heart Blog. Beta blockers are used to treat various conditions, including high blood pressure.

Here is a list of conditions typically treated with beta blockers. Source: The Mayo Clinic

  • High blood pressure
  • Irregular heart rhythm (arrhythmia)
  • Heart failure
  • Chest pain (angina)
  • Heart attacks
  • Glaucoma
  • Migraines
  • Generalised anxiety disorder
  • Hyperthyroidism
  • Certain types of tremors

Side effects of beta blockers

Side effects will sometimes occur in the first few weeks while adjusting to a new medication, then subside as your body adjusts to the medication regime. It is always important to communicate how you are feeling with your doctor. The following is not a full list of possible side effects but mentions the main ones that may occur. Source: The Mayo Clinic

Common side effects

  • Fatigue
  • Cold extremeties
  • Headache
  • Upset stomach
  • Constipation
  • Diaorrhea
  • Dizziness

Less common side effects

  • Shortness of breath
  • Trouble sleeping
  • Loss of sex drive
  • Depression

Beta blockers can be a poor choice for a competitive endurance athlete

The calming effect of beta blockers makes them attractive for some athletes whose performance depends on balance (e.g., gymnastics) or a steady hand (e.g., archery, shooting). This use of beta blockers by athletes contravenes the World Anti-Doping Agency (WADA) guidelines on the use of medications or substances for athletes during competition.

For endurance athletes, beta blockers will affect your workouts in several ways and can trigger a range of undesirable symptoms.

Tired triathlete

Reduced exercise performance

Beta blockers will reduce your exercise performance by decreasing either maximal heart rate or the strength of your heart contraction, or both. Your cardiac output (the volume of blood pumped by your heart per minute, mL blood/min) and VO2 max (the volume of oxygen you can consume while exercising at your maximum capacity, measured in millilitres per kilogram of body weight per minute, ml/kg/min) are compromised. This will create that sensation of sluggish workouts and physical unresponsiveness.

Increased perception of exertion

Beta blockers can give you an increased perception of exertion because they slow your heart rate and prevent an increase that typically occurs with exercise. You may struggle to work out at previous heart rate levels before taking beta blockers and may never reach your previous target heart rate.

Postural hypotension

Beta blockers might make you feel lightheaded, dizzy or faint when standing up too quickly. You may have trouble climbing stairs or bending over.

Impaired temperature regulation

Beta blockers slow the heartbeat and so limit the body’s ability to circulate blood fast enough for heat exchange at the skin’s surface. Beta blockers can therefore impair your temperature regulation during prolonged exercise, predisposing you to dehydration and hyperthermia. This is something for athletes to consider when training or racing in hot weather.

Ways to minimize the effects of beta blockers on your athletic activities

Sometimes, athletes will have to weigh up the pros and cons of beta blocker therapy and many will end up making the decision to take a beta blocker. Despite the disadvantages to sport performance, the overall improvement in quality of life and/or reduction in the risk of having an adverse event can make taking a beta blocker the best line of heart health management. It’s all about taking into account the data relating to your own circumstances and making a personal risk assessment that enables you and your doctor to decide on the most appropriate therapeutic course of action for you.

If you are taking a beta blocker and remain keen to participate in sport activities, here are some tips that might help you on your sport health journey.

Focus on ‘participation’ not ‘racing’

The shift in mental attitude from ‘competitive athlete’ to ‘sport participant’ can be on of the most significant changes an athlete must make when diagnosed with a cardiac condition and/or facing life long medication therapy. This transition may not be easy for some athletes and will be a gradual process to work through, as described by an athlete called Sue  at Pacemaker Club.

Posted by Sue, 29/08/2013, at Pacemaker Club: “… it’s caused me to face a changed self-image as a runner. I’m not the runner I was, and I don’t think I ever will be. I don’t get faster or stronger anymore. I do think it’s the ICD and not the beta blocker, although I could be wrong. I’m gradually changing my expectations for myself, and telling myself that I’m damn lucky that I’m even alive, never mind able to run. But it’s a difficult transition; so much of my self-pride has always been wrapped up in being a runner for so many years.”

Another athlete, Tracey E, accepts the shortcomings of beta blockers, flipping what might be perceived as a negative outcome (“I may be the slowest and the last”) into a positive accomplishment (“I do finish and I figure that puts me ahead of the most of the population”).

Posted by Tracey E, 29/08/2013, at Pacemaker Club: “I do Crossfit. I can definitely tell a difference and I do feel the bb holds me back, but I don’t let it stop me. I remind myself that without it I can’t work out at all so suck it up buttercup 🙂 I may be the slowest and the last done many days, but I *do* finish and I figure that puts me ahead of most of the population.” 

Reset your heart rate monitor settings

If you are wanting to use a heart rate monitor to guide your workouts, you can consult a doctor to calculate a readjusted target heart rate for you to work to. This usually requires a baseline exercise stress test to measure how hard your heart pumps while taking beta blockers.

Alternatively, you can use a Rate of Perceived Exertion (RPE) scale, which uses your judgement of how hard you are exercising (based on effort, breathlessness and fatigue). With an RPE scale, you can learn to regulate your effort to gain maximum benefit from your workout.

One rule of thumb: If you can’t talk while exercising, you are probably overdoing it .

Rate of Perceived Exertion (RPE) Scale:

Rate of Perceived Exertion (RPE) Scale

Change your warm up strategy

A longer and more gradual warm up and cool down are advised for athletes on beta blockers, to minimize medication side effects.

Schedule your medicine intake around your workout

Please be careful: you should discuss your medication scheduling with your doctor before making any changes.

The testimonials of many athletes suggest you might try taking your beta blockers either well ahead of or immediately after your training sessions, so that you have the least amount of the medication in your system when you are exercising.

Posted by slowmo, May 2012, at Marathon Swimmers Forum: “Yes, I was getting ready for the sears stair climb ended up on a beta blocker and went from running 2,000 to 3,000 steps down to 700 during my workouts. The drug acts like a throttle so what I learned was to take my meds after my workouts, this way I hit the 23hr mark of it being in my system which let me workout at higher rate if that makes sense.”

Posted by Chris_OD, September 2012, at Marathon Swimmers Forum: “Take the medicine after the workouts so the exercise performance is least affected. If one takes a beta blocker before an exercise session (especially a short-acting beta blocker), one will feel like one’s heart is pumping so hard it wants to beat right out of one’s chest. The pulse will be slower than normal, and will not rise accordingly to allow for the body’s need for the heart to provide more oxygen to the muscles [ … ] Personally, if I were taking a beta blocker, I would take a long-acting, once daily dosage form, after my workout each daily: atenolol.”

Posted by Snail, 10/07/13, at Runners World Forum: “I have subjectively noticed a difference between when I take and don’t take the beta blocker the AM before a tempo run. So I have adjusted the way I take it. I used to take it first thing upon awakening, but will now wait until after my run, depending on what time of day that is, so my run will be at the tail end of the therapeutic effect when it won’t have as much of an effect on my heart rate. I also may skip it the day before a race, though I would obviously not advise this for anyone else without speaking to their doctors.”

Warning: Do NOT suddenly stop taking a beta blocker!

 You should not abruptly stop taking a beta blocker because this may actually trigger chest pain, irregular heart rhythms or a heart attack. Consult your doctor if your beta blocker is not working for you or causing you unpleasant side effects. Weaning off beta blockers must be done under careful supervision.

What about having a conversation with your doctor?

What I find surprising is the number of endurance athletes who take exactly what their doctors tell them to take and don’t ask any questions about their medications. And, the same athletes won’t necessarily connect symptoms they might experience with medication side effects. If they do draw a connection, then they may err towards medication non-compliance; in other words, they may avoid taking their medication altogether or only sporadically.

So what about having a conversation with your doctor? Well, many athletes express dissatisfaction with doctors who appear clueless about the significance of accommodating a sport lifestyle into their patient’s personal health management plan.

I would encourage you to be completely open with your doctor or cardiologist on the level of exercise that you do. Your idea of ‘moderate’ might be a cardiologist’s idea of ‘strenuous’. It is important that you explain clearly to your doctor your lifestyle expectations. Talk about other drug options (e.g., ACE inhibitors, calcium channel blockers, etc.). Seek a referral to a sport physician if you feel your own doctor is not accommodating your needs. A second opinion can be reassuring.

World Anti-Doping Agency (WADA) listing

Beta blockers are included in the World Anti-Doping Agency (WADA) listing of medications or other substances banned for use by athletes during competition, in specific sports and under certain conditions. You and your treating doctor need to be aware of WADA restrictions if you choose to use medications on the prohibited list. Refer to the 2016 Prohibited List, available for download from the WADA website.

A useful fact sheet

The Atrial Fibrillation Association (AFA) Australia has produced a very useful information sheet on beta blockers which you can access at their website, here.

Author: Kara Gilbert @ KMG Communications

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