Book excerpt: How pushing to extremes led an amateur cyclist to ventricular tachycardia
Republished with permission of VeloPress from The Haywire Heart: How too much exercise can kill you, and what you can do to protect your heart, by Chris Case, Dr. John Mandrola, and Lennard Zinn. Learn more about heart conditions in athletes at velopress.com/haywire.
Mike Endicott was always interested in endurance sports, even when he was a teenager. He hiked the Appalachian Trail in 1973 when he was 18 years old. He moved to Boulder, Colorado, in 1980, to take advantage of the climbing opportunities in the area. Though he came as a rock climber, he soon became a fan of trail running.
“By nature I’m a person who likes to train. I race to train; a lot of people train to race. [Racing] was kind of anti-climactic. I use racing as kind of a gauge as to where you’re at, but I much prefer to be just out doing stuff. I just like the movement and activity, being outside,” Endicott says.
His interests evolved again, so that six months of the year he would be Nordic skiing and the other six months would be devoted to riding road and mountain bikes. He was moving nonstop.
He was an independent sales representative, managing sales in Colorado, Utah, Wyoming, and New Mexico, in the cycling and outdoor sports industries. A typical day might include a fine mix of work and play. If he was working in Moab, he might take much of the day off to do a solo ride along the White Rim Trail, a 100-mile epic mountain bike ride through Canyonlands National Park. Then he’d eat, go into town, and make his work visits. Then he’d drive to Salt Lake City and get ready for the next morning. He was working seven days a week.
“I was burning the candle at both ends. I was having a ball. I was working, I was making a good living, but, boy, was I burning it and I didn’t realize it,” Endicott says now. The result was that any racing Endicott did would be hit or miss, solid or so-so. “A good coach would have told me, ‘Oh, I know what’s going on.’ It was classic: I was chronically overtrained. That was the beginning of what probably caused all my issues. Probably. Likely. Nobody will ever know, but that’s a likely cause: chronic overtraining,” he says.
Endicott lived this way for years. He’d ski a marathon race in Yellowstone on Saturday, then drive to Steamboat and do another marathon on Sunday. He loved it. And he was able to work in between.
“It’s not good for you though,” he says, looking back at his life now. “But who would know? You would think it’s good for you.”
Then, one day in 2005, he headed to Devil’s Thumb, a Nordic ski area in the Fraser Valley of Colorado. “I had created the perfect storm over a good 20-year period, but it all came to a head here because of the week or two prior to this race,” he said.
Before heading to Devil’s Thumb, Endicott had been in Boston at a sales meeting. Immediately after the sales meeting, he returned to Colorado and went straight to Breckenridge to do a ski race. He had a mediocre race, a “spit-blood race,” one that hurt. He then drove straight to Steamboat Springs to conduct clinics, throwing in an interval workout and feeling good. He hadn’t slept well the night before heading to Devil’s Thumb, and he knew he was tired. But, like so many of us, he just liked being out there. He felt he needed to get into shape, since it was early season, and this would be good for his form. He didn’t eat much before the race except for two big Starbucks coffees. An hour from the start, he downed a few caffeinated Gu packs. It was cold, around zero degrees, overcast, with light snow falling and a bit of a breeze swirling ’round. All of the ingredients for the perfect storm were in place.
“I’m having a good race, and probably about a third of the way through, I could see the people I wanted to reel in. . . . I was having fun, going after it,” he says. “I saw one little nice rise and thought, ‘OK, I’ll punch up this thing’ because there was a guy right in front of me that I wanted to reel in. We were always humorously competitive. Punched up over this rise and all of a sudden, I don’t feel good, something’s not right. Something was beating inside my chest. No pain, no discomfort, but I was a little dizzy.”
Endicott stopped to catch his breath. He was hyperventilating. As he stood beside the trail, people started to pass him. Friends asked if he was okay. He told them he’d be all right. He told himself to keep going because he just couldn’t figure out what was happening. He tried to ski. He wasn’t racing any longer, as most of the field had passed him by, but he skied on. He felt like he was drunk. He could hardly stay up on his legs; he would collapse and get back up, his heart still doing something strange inside his chest.
“I knew something was bad. I knew the race was over. It was survival mode: ‘I got to get back to the lodge,’” he says. “Luckily, I knew it was mostly downhill so I got off the racecourse, which was a mistake in retrospect.”
By the time the last skiers had passed by, Endicott was done; he collapsed in the snow and began to die. He was on his back, barely maintaining consciousness, in a skin suit, in the snow, in zero-degree weather. There was no pain, but he couldn’t catch his breath. He tried to yell for help, but he could barely make a noise; he could only wave his pole.
“Fairly quickly I realized I’m in deep shit here. Basically I figured I was done, this was it,” he says. “It’s interesting . . . at the time, my emotions were . . . I was frustrated. It was not on my list of things to do because I was kind of a type A, my dog was in my truck, we were going to go out and do a ski when I was done, I had work to do that afternoon, phone calls to make. It just wasn’t on my list of things to do—to die on the ski trails. I was pissed [laughs]. I was beating on my chest with my hands saying, ‘Come on, something’s got to work here.’ So I struggled in and out of consciousness out there in the snow for about an hour. I don’t know how long I was out, and then I’d come back again, and then I’d try to look around and then I’d get dizzy again. It was ugly.” By pure chance, two of his friends went out for a cooldown after their race and the awards ceremony. They saw Mike wave his arm out of the corner of their eyes and skied to find a fallen friend dying in the snow.
As they snow-mobiled Mike out on a sled, he was belligerent, trying to fight whatever it was he was going through. “I was just fighting the whole thing, pissing and moaning, yelling, just thinking this is stupid; this is not what you would expect,” he says. “I was even swinging at my buddies, saying, ‘This is ridiculous!’”
Mike was in ventricular tachycardia. The result was sudden cardiac arrest. He was 50. It sounds grave, and it was, but by his own admission, it was a miracle he survived.
Doctors ruled out any plumbing issues in Endicott’s heart. Had he visited a clinic the day before the race, it’s more than likely that nothing would have shown up on paper, on any test, that would have led the doctors to stop him from racing.
“They would have pronounced me healthy as a horse,” he says. “The ECG would have been perfect because I wasn’t having any symptoms. Nothing was symptomatic whatsoever. No PVCs, no weird rhythms. Everything on paper [was fine], with the exception of the little bit of artery disease—not much more than a lot of people that age.”
After looking at a lot of different cases and talking to a number of doctors, Endicott came to a conclusion: “I did all this to myself — by personality. And if someone had come to me before this happened — and this is a key part of reality — and said you need to back off because this is your future, would I have changed anything? Probably not. I would likely do the same activities, but I would rest and recover more. Just because that’s the nature of a lot of us. We enjoy doing it, we’re probably doing it too much, we’re selfish about it, and we’re going to be in denial, and that’s a problem that a lot of these electrophysiologists have when we ask ‘Why me?’”
One of the problems with a lot of athletes — the problem with Endicott — is that they can’t stop asking why. How could this happen to me, someone who has built his life around being active? It just didn’t make sense. Endicott was in denial, even after it happened. But he wasn’t unique. The most difficult component to life after heart malfunction, for many, is the psychological struggle.
He and others like him are desperate to know what went wrong. They want the cardiologist to help solve the puzzle. But doctors will not speculate. The doctor’s job is to stabilize patients, keep them alive, and try to give them quality of life. In Endicott’s case, that meant having three failed ablations before a fourth successful attempt. Because his was exercise-induced tachycardia, he would not only be awake for the procedure, but would be caffeinated and given intravenous adrenaline to improve the chances of inducing arrhythmia while he was on the table. Catheters were sent through his femoral veins and arteries, on both sides, and led into the heart. For his first attempt, he lay awake for eight hours; it failed to identify the source of the arrhythmia.
For the next attempt, doctors at the University of Oklahoma, one of the most experienced facilities in the United States, tried for sixteen hours to locate the culprit tissue. Still, they couldn’t induce tachycardia.
“It was a brutal session. It was endurance. But they couldn’t find a focal point. So they did some burns; both times they burned some places where they thought the problem was,” Endicott says.
Though his doctors believed they had ablated the problem, within the next few months Endicott was experiencing episodes again. Yes, stubborn as he was, Endicott was going out and doing the things he loved to do. And, yes, this was leading to more episodes of V-tach. Eventually, it was determined that his condition was too perilous not to insert an implantable cardioverter defibrillator (ICD). Life carried on.
The ICD can be a beautiful device, shocking the heart back into rhythm, saving a life from the inside out. But it isn’t without its discomforts. It is, according to Endicott, like getting hit by lightning. If you’re on a bike when it happens, it’s going to knock you off. If you’re standing up, it’s going to drop you to the floor. It’s a very quick shock. It determines that the rhythm of your heart is out of synch, it determines what kind of rhythm you need, and then it instantaneously reboots you. Your heart actually stops so it can restart the right way.
It may sound like a miracle, and it can be. But it can also lead to catastrophe, in what is called an electrical storm. Endicott suffered such a storm when he was performing as a member of a band at a retirement community. His instrumental solo bumped his level of adrenaline and he went into V-tach. “I would go into V-tach, I would get the shock [from the ICD], and the shock would convert me into sinus rhythm for a couple of beats, but there was so much adrenaline that I would get thrown right back into V-tach,” Endicott says. “It was a cycle, and it was brutal. It’s going to do its job until I’m dead.”
The folks gathered around him didn’t know what was happening. He was able to hide his embarrassment by slowly leaving the area where the concert was taking place, finally curling up in a ball on the floor in another part of the community. He had only one to one-and-a-half minutes between shocks. When the paramedics arrived he was still convulsing. They weren’t able to detect a heartbeat, so external defibrillation was used to return his heart to a normal sinus rhythm. He was lucky. He had suffered through 32 consecutive shocks from the ICD.
“We’re talking about something that feels like 1,000 volts. It happens quickly but you’ll see a flash. . . . It was basically like being tortured,” he says. The result was an acute case of posttraumatic stress disorder (PTSD). It was something that Endicott never knew anything about until it was upon him. He was rewired, yet again. Little things in life, as happens with PTSD, became too much to deal with — beyond-category climbs, as he puts it. It took him two years to recover.
Finally, in 2009, he was referred to the cardiology department at Brigham and Women’s Hospital in Boston. Their top electrophysiologist, Dr. William Stevenson, reviewed the case and decided to try one more ablation. This time the procedure was performed on the outside surface of his heart. It worked — after a four-hour examination.
“If I read a story like this I wouldn’t believe you. I would be in denial because I love doing things like this. I still try to find ways to be able to do things like this and I’ve been through the wringer,” Endicott says. “I’ve gotten a little smarter about it. But I’m also practical and pragmatic and I could always see the humor in it, even when I was lying in the snow and I knew I was likely not going to survive. I didn’t think I was going to make it. There were no white lights for me. I was scared and I was coming out of being clinically dead. I even had to laugh to myself and say what a waste. ‘I’m here lying in the snow . . . at least I’ll be well preserved [laughs].’ But I was very frustrated because of that lack of control.”
The complexity of the heart, the body, human physiology, and genetics makes it extremely difficult to predict when and in which heart something catastrophic like this will take place. Why did this happen to Endicott when it did? Well, there are 50 years of cumulative variables that would need to be considered to fully understand what went wrong on that cold, crisp day at Devil’s Thumb.
Some of it is genetic. Did he have a tendency toward higher blood pressure? Yes. What about cholesterol? He was always well below average for that, like many athletes with a healthy diet. Plaque buildup? A little, but nothing out of the ordinary.
These are the little clues that would be easy to dismiss, but combined with his stressful lifestyle, filled with epic endurance events and a somewhat frantic employment schedule— the acquired stressors that this chapter shows can lead to arrhythmia — they sketch a picture of an impending storm on the distant horizon. Add stress and cold weather, and that picture quickly became an IMAX 3D feature film on dying in the woods, alone.
“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,” Endicott says. “I’ve done the research, folks. It happened to me. I’ve had friends that are either dead or alive that it happened to. The research is out there; listen to it. Now they’re finally starting to acknowledge those facts and those examples that something is going on.”