Aside from the moment I wrote a single sentence about what I’d endured as a child then deleted it from my computer screen without even rereading it, this story was the first time I wrote with any kind of honesty about my life and family. I was supposed to write a simple story for about the role of the heart in cycling. I’d dropped in the detail about the dog in an early draft, and my editor, Steve Madden, pushed me for more, as hard as he thought he could without collapsing the story. I’ll always be grateful that he did, because that opened everything up. Before, I’d always painted my youth and my family as a comic tragedy involving heroically lovable misanthropes. In reality, we’re a bunch of fuckers. This isn’t anywhere near the best story I’ve written, and there ended up being some sloppy factual errors I later corrected when I did more research, but it was the seed of my book,Ten Points, so it means a lot to me.
Last Sunday, toward the end of a sunny afternoon perfected by a wind just brisk enough to tingle my lungs with a barely perceptible reminder that I was breathing, our little riding group turned up onto a gravel road that leaped out of the valley at about 10 percent and would climb more than 1,700 feet in four miles. I felt loose, and strong, and within a few strokes I gapped two of my friends. Another matched wheels with me for a few feet, then rose out of the saddle and danced away. I shifted up two gears and stood on the pedals. Then I did something my new doctors, specialists at the Cleveland Clinic Heart Center, had warned me to never, ever do: the math.
The process that led to me crunching the numbers of my cardiac mortality amid an exquisite ride had begun five months earlier, when Ed Burke died of a heart attack while climbing a hill in Colorado during a group ride. Burke, 53, was a physiologist who helped shape cycling’s principles of aerobic training, and a pioneering advocate of the use of protein drinks for recovery. Even if you never knew Burke, he influenced the way you bike. I had known him. I’d ridden with him. And I’d asked myself the Jim-Fixxian question that every cyclist who heard of his death at least momentarily pondered: If it happened to him, with all he understood, couldn’t it happen to me?
In my case, the question ran deeper than newsy curiosity. My father died of a heart attack at 47; his brother at 56. And when I heard about Burke, I was temporarily bedridden with a herniated disc. Over 11 days of immobility, I watched my 4-year-old daughter first miss our daily rough-housing and playacting, then become accustomed to amusing herself without me. I could not only imagine Natalie growing up without me, I could see it happening. I vowed that when I could move again, I would do as much as I could to determine my own destiny. And I had, submerging myself in research about cardiac health and embracing a battery of tests at the Cleveland Clinic, named the country’s best hospital eight years running by U.S. News and World Report.
Back on the hill that Sunday, five months of medical statistics and analysis combusted. I knew, for instance, that a landmark study in The New England Journal of Medicine put the chance of exercise-induced death at 1 per 13,000 for a typical man who, like me, exercises vigorously more than 140 minutes a week. I also knew, thanks to a $600 Advanced Metabolic Marker screening test, that I’m not typical: A spiral of my DNA, just one of the curses I inherited from my father, gifted my body with a predisposition to produce way too little of a specific type of cholesterol called apolipoprotein A-I, and slightly too much of another called apolipoprotein B — which makes me genetically 4.4 times more likely than the average guy to die of a heart attack.
I downshifted and sat back in the saddle. I watched Dave rise away from me. The labored breathing of my two trailing friends grew louder and closer. I set my jaw, then punched up some gears — and another stream of numbers: Ride aerobically, my doctors had told me, at 80 percent or less of your maximum heart rate and your risk of dying is about the same as when you’re sitting at your desk, or watching a movie, or doing any of life’s routines. But rise above aerobic intensity — which I was about to — and your risk increases about 7 times.
Intellectually, I understood that the equations I was jamming together were as incompatible as Campy and Shimano. But I could no more stop them from flowing together than I could stop my friend Dave from dropping me on this hill. All I could do was chase. Say four rides a week times 52 weeks times 22 seasons divided by 7 times 4.4 into 13,000 . . . .
If I stood on the pedals on this gravel road of no significance on a ride of no significance other than that it was the first warm day my friends and I had all gotten out together, I calculated a staggering one in 11 chance I would die. Preposterous? Absolutely.
Even so, the muscle in question would not stop asking me if I’d rather catch Dave at the summit or live to romp around my yard later that day with my wife and daughter.
But what kind of father, what kind of husband, not only never tops a hill first but never even tries?
Wouldn’t I actually be living more if I died on some meaningless climb rather than enslaving myself to a lipoprotein that would eventually kill me anyway? Except if I blew past that abstract, childish nobility and just sat in, crested second or third or, who would even really care, fourth among four, then I’d ride home and sit at the kitchen table with my wife and daughter. The dog would want to be petted. The water glass would be cold. I’d have a sandwich. Mundane activities, not worth mentioning at all, yet, given all I knew, Ed Burke, tell me, wouldn’t it taste larcenously sweet?
My thumb twitched against the Campy’s upshift button. My goddamn heart.
Aside from the fact that mine is more likely to kill me than most of yours, our hearts are not much different. About the size and weight of a water bottle missing a few sips, at rest our hearts pump about 2.4 ounces of blood with every beat, on average 100,000 times a day. Muscled up entirely with slow-twitch fibers, the heart is the ultimate roleur – not explosive like a sprinter or climber but able to lay down a powerful pace it can hold seemingly forever. It starts pumping in the seventh week of fetal development (before it is even inside our bodies) and has the endurance to beat about 2.6 billion times before stopping, yet also the power to push about 85 bathtubs worth of blood through your body’s 60,000 miles of veins, arteries and capillaries each day. At peak speed (and on the shortest route), a blood cell can be propelled from heart to body and back in about 20 seconds.
“It is an ordinary miracle,” the CCHC’s Dr. Gordon Blackburn said when I asked him if he ever took the muscle’s function for granted.
Because you’re a cyclist whose heart has been trained to pump more blood than normal, it’s probably a little larger than usual, and a little thicker; the walls are likely a tweak over 1-cm thick, compared to an average range of 0.6-1.1 cm. In an untrained person, the outsize measurements would be a sign of heart disease. Three-time Tour de France winner Greg LeMond was once denied a life insurance policy after a cardiac exam indicated an enlarged heart, until the company discovered his occupation.
“In terms of physical structure, you and Lance Armstrong have essentially the same heart,” says Blackburn. You, me, even Lance Armstrong all have tickers similar enough to fetch about $60,000 in a blind auction on the transplant black-market.
“The big difference is efficiency,” says Blackburn, who, as a specialist in cardiac rehab, is an expert at boosting efficiency. One of his patients, Cleveland lawyer and cyclist Cal Kirchick, had a heart attack mid-ride in 1991 (“I thought I was just having a bad day,” says the Museeuw-tough bike commuter, who finished the ride before going to the hospital) then recently came back to max out in a stress test at 15 mets, which means he was able to hold an exercise intensity 15 times harder than his resting metabolic state; a typical result is 7-10 mets, says Dr. David Moliterno, my primary CCHC doc.
Within the first 12-16 weeks of riding, the heart itself becomes stronger. It begins pumping more blood with each stroke and working more efficiently at a pace closer to its maximum, improving your aerobic capacity 15 to 20 percent. (After that, you have to train for an entire season to gain about another 4 percent.) Your resting heart rate slows far below the national average of 72 beats per minute (mine is around 57) and your heart becomes adept at ranging from rest to max, which, off the bike, safeguards you from arrhythmia, the onset of irregular heartbeat that can trigger a heart attack; on the bike, it lets you hammer and recover. This is where the pros and the rest of us part company. Miguel Indurain, five-time-winner of the Tour de France, reportedly had a resting heart rate of 28 bpm. Climbing hard in the mountains, he could amp his pulse to 190, then plummet back to recover at 60 bpm within 30 seconds.
As you ride through the seasons, your cardiovascular system adapts to meet the demands you place on it. Capillaries multiply, so muscles have more pathways to accept oxygen and offload waste, and the lining of the arteries undergoes biochemical changes to become more responsive and better able to dilate; this decreases resistance to blood flow, so your blood pressure drops, often below the healthy figures of 130/85. (Your sensitivity to insulin also improves as your body becomes better at managing glucose, or fuel, which also lowers blood pressure.) Your blood becomes richer in oxygen-carrying cells. Thanks to an increase in an enzyme called lipoprotein lipase, your body becomes better at removing fats from your bloodstream. Triglycerides and LDL cholesterol, the type associated with an increased risk of heart disease, drop. HDL, the “good” cholesterol associated with healthy hearts and long life, increases about 10 percent.
The cycling heart is one of the strongest on earth. So why is mine going to kill me?<
One thing my father’s friends always told me, and still tell me, was that he had heart. I never disagreed with them. I just argued with myself over interpretation. When he could avoid alcohol, when he’d told yet another overbearing suit to go to hell and once again found a better sales job the same day and celebrated with a new car or, once, even, a new house, and when he wrestled a home-run baseball up from under a mob at Wrigley Field, and when I loved him, all those times I believed that having heart meant never letting failure beat you down. When he could not stop drinking, when he couldn’t keep even a job cleaning shoes at a bowling alley and I had to stand in the free lunch line at school, when he shot my dog in the leg because I forgot to feed it one morning, and when I hated him, all those times I knew that what passed for heart meant you never understood you’d been beat.
His shifting brand of heart seemed like one more family curse that bicycles had helped me escape. I’m the only adult athlete in my bloodline. Ever. I eat better than anyone who shares my name. I never smoked cigarettes. I don’t beat my wife, or slap my kid around. I’m not going to hang myself in jail like my Uncle Smokey, or get stabbed to death over crack like my cousin Brian. But I have my father’s heart.
The first mistake any of us make is choosing the wrong parents. Your chance of developing coronary artery disease (CAD), the most common form of heart disease, which is in turn the most common killer in the U.S., with about 460,000 victims per year, is anywhere from 70 to 80 percent genetic, depending on which researcher you believe.
CAD begins developing when plaque — a combination of fats, cholesterol, cell waste and proteins — builds up inside artery walls. Contrary to popular belief, says Dr. Steven Nissen, a Cleveland Heart Clinic researcher (and devoted cyclist) who developed a camera tiny enough to slide inside our pipes, the artery doesn’t narrow; it dilates its outside walls to accommodate the plaque lining while maintaining the same blood flow — until you experience what doctors call a “remodeling,” which, despite the polite terminology, is really more like a volcano erupting. The outer, calcified surface of the plaque ruptures, spewing out a clotted mess of fats and waste. Making things worse, blood platelets that sense injuries speed to the rupture as a natural defense mechanism and cause proteins at the site to coagulate. Your artery can fully or partially clog immediately, or the whole mess can flow downstream until it hooks up with another clot that has partially blocked a blood line.
As your heart stops receiving blood and the oxygen it carries, the muscle begins dying. You’ll most likely feel this as a pressure or burning in your chest, as well as an unusual shortness of breath. The pain might spread to your shoulders, arms or jaw. But researchers at the University of California, San Francisco, report that nearly half of all heart attack victims report symptoms of dizziness, lightheadedness, stomach pain, nausea and vomiting.
Once thought of as an old person’s affliction, coronary artery disease is present in 60 percent of people in their 30s, according to Nissen’s miniature camera; 37 percent of those in their 20s; and, most shockingly, in one of six teens. Or, as Dr. Charles Pollick, a heart specialist at Los Angeles Cardiology Associates who developed a stress-echo diagnostic test especially for cyclists says, “If you live in the Western hemisphere, there’s a chance you’’re at risk.”
So you, like me, are almost certainly a statistic. Chances are your genetics aren’t as bleak as mine; but maybe they’re worse.
The one thing we have in common for sure is the 20 to 30 percent of control over heart disease that isn’t inherited. Two decades of cardiovascular play, for instance, and the foods that have fueled it, have dropped my natural heart-attack risk level, of 4.4 times more likely, down to 2.1. And thanks to the advanced blood screening test I took — which looks not just at total cholesterol but lipoproteins, triglycerides, homocysteine, ultra sensitive CRP and other risk factors — I know that taking Niaspan, a prescription-level form of the vitamin niacin, could get my chances down to just about average.
When I took my echo-stress test, which let doctors watch my heart in real time as I pedaled, I started with 90 rpm against 100 watts of resistance. There’s no warm-up, so your heart ramps up faster than it does on a ride. Every 2 minutes, the supervising doc increases resistance 50 watts; most people start at 50 watts, he told me, and are done in 7 minutes. At 200 watts, I said, “I’ll hit 160 bpm here,” and I did. At 250 watts, I predicted a 174 heart rate and nailed it. Ten minutes in, at 300 watts, my heart banged against my chest more than 3 times a second. “I got. More beats,” I panted.
“No, finish the two minutes and we’re done,” said the doc.
“Ain’t done,” I gasped. “Go 350.”
“We have what we need,” he said, and unplugged me.
Any of us can have our cardiac muscle measured, its performance quantified, its motion captured on video. No one can tell us how much heart we have. It’s not the physical muscle our forebears give us, but the intangible heart that will determine how we live. In one of its oldest forms, kred-dh, the root of cardiac, the word heart meant “to place trust,” or “to believe.”
I climbed that mountain hard on that Sunday. I might not the next time, because I don’t have an answer about how I should live with my heart. Every ride answers itself. Death is not worth attacking every hill or chasing every break, but life is not worth never attacking a hill or chasing a break.
I climbed that mountain hard and I rode all alone over the top. I rolled along and pretended I was Lance, pretended I was Greg and the great Gilbert Duclos-LaSalle, who won two Paris-Roubaixs when he was my age, and I pretended I was the best part of my father, and I pretended my daughter Natalie stood beside the gravel road cheering, and I rode to an intersection, and I stopped to wait for my friends, and I felt my heart beating.
Originally published in Bicycling magazine, October 2003