Pulmonary embolism, a silent killer: What cyclists should know
Editor’s note: This article is a general overview of pulmonary emboli and does not constitute medical advice. Always consult your physician if you think you are suffering from this or any other medical condition.
On November 17, 2006, Mike Friedman (Optum-Kelly Benefit Strategies), 24, felt an excruciating pain rip through his torso. “I’ve never been so short of breath,” he said. “It was like a dull knife ripping apart my chest.” In the middle of watching the movie “Cars,” he turned to his date and said, “We need to get to a hospital. I think I’m having a heart attack.”
Forty minutes later, Friedman was under evaluation at the University of Pittsburgh Medical Center, not for a heart attack, but for a pulmonary embolism, a potentially lethal blood clot in his lung.
Pulmonary emboli (PE) are silent killers. Often with little prior warning, nearly 300,000 people are killed every year by blood clots which lodge in their lungs (Kahanov and Daly, 2009). There is no greater cause of sudden death in the healthy population than a pulmonary embolism (Goldhaber, 2004).
First, a clot called a deep vein thrombosis (DVT) forms, often in the calf. The DVT travels from the veins to the right side of the heart which pumps the clot to the lungs. Untreated, this blocks blood flow to the lungs and can ultimately cause cardiac arrest. In total, over 900,000 people are stricken with pulmonary emboli every year. Many of those hit are otherwise healthy athletic people. (Andersen et al, 1991).
PEs are not unheard of in the peloton. Rwandan cycling pro Adrien Nyonshuti (MTN-Qhubeka), the focal point of Tim Lewis’s book, “Land of Second Chances,” lost his 2013 season because of his PE. Vuelta a España champion Chris Horner suffered one in 2011. Top professional Frank Vandenbroucke wasn’t so lucky. His embolism was fatal.
It was the coalescence of four crucial factors that caused Friedman to totter down the UPMC emergency department hall that night.
In late October of 2006, the rider affectionately known as “Meatball” had surgery to remove a recurrent saddle sore. What he didn’t know at the time was that he carries a genetic mutation called Factor V Leiden — one of the approximately 16 known genetic variants that can cause clotting disorders. The surgery, coupled with Friedman’s genome, kicked his clotting mechanism into high gear.
On November 6, he drove 1,600 miles non-stop from his home at the Olympic Training Center in Colorado Springs to his family in Pittsburgh. Fueled by little more than truck stop coffee, dehydration became Friedman’s buddy during the drive. Worse, periods of immobility, such as lengthy drives and airplane rides, often trigger DVT formation. Friedman’s calf cramped badly during the drive. Once the clot took root in his leg, the cramping was constant, an early warning sign that a DVT had formed in his leg.
When Friedman arrived in Pittsburgh, he began to train again. Unable to sit comfortably, he went out for runs. He also did 75-mile rides — without a saddle, but with a DVT in his calf.
Surgery, genetic predisposition, a lengthy drive, plus dehydration — fortunately for Friedman on his date night, he avoided the urge to tough it out, and got to the ER.
What are the warning signs that should alert you to seek immediate evaluation?
1) Shortness of breath — typically appears suddenly and always gets worse with exertion.
2) Chest pain — Not only “heart attack pain,” but pain when you draw deep breaths, cough, or bend at the waist. It does not go away.
3) Cough — especially bloody sputum.
4) Leg pain and/or swelling — usually in the calf. This is a tough one for cyclists. Our calves always ache. One-sided swelling is a tipoff. Friedman’s was only in his right calf below the knee.
5) Clammy and/or discolored skin — Friedman’s leg took on a reddish hue.
6) Irregular heartbeat.
7) Anxiety, lightheadedness, and/or dizziness.
If you’ve got two or more of these symptoms, it’s time to get evaluated immediately. Untreated, 30 percent of acute PEs result in death (Horlander K.T., et al). Once at the hospital, several tests are commonly used to diagnose a DVT/PE episode.
Typically, a chest x-ray is taken to rule out other disorders which mimic a PE. An ultrasound exam of your legs can confirm the presence of a DVT. Standard blood work often includes a D-dimer test, which can tell if your body’s clotting mechanism has been engaged.
A CT pulmonary angiogram is considered the gold standard for PE diagnosis. A small amount of contrast medium which contains iodine is injected into a vein in the hand or arm. The exam is quick — images are taken shortly after injection and take just moments to gather. Any emboli are seen as dark against the white background of the dye within your pulmonary circulation.
Now that your doctors have diagnosed you with a PE, you are likely to be treated with a variety of anticoagulant therapies. How long you’ll remain on anti-coagulant therapy, and when you can get back on your bike are critical questions for any cyclist.
Straightaway, you’ll need patience as the damage caused by the blood clots in your lungs and legs takes time to heal. Swelling of the legs is often worse after a DVT, so your physician may order you to wear compression stockings to keep it at bay. You might find that the mere act of walking up stairs leaves you breathless for several weeks post-PE. Base miles will be the order of the day for awhile.
PEs are complex medical management issues for physicians. It may take several weeks of tweaks until your personal physiology and the medications begin to act in harmony. While the outlook for a fit athlete’s return to active riding is far brighter than for the population at large, you might find yourself on anticoagulants for some time.
Most likely, you’ll be back on the bike, but perhaps not as strongly as Friedman. In May of 2007, six months after suffering a PE, Friedman raced the Four Days of Dunkerque. In December of 2007, Friedman won the pre-Olympics scratch race on the Beijing velodrome which cemented his spot on the US Olympic long team. And in April of 2008, he raced the cobbles of Paris-Roubaix, as he rode in support of fourth-place finisher and Garmin teammate Martijn Maaskant. Nice comeback.
Special thanks to Dr. Chris Roseberry, MD, FACS — the finest cyclocrossing surgeon in Exeter, NH.