Dying Young

THE PREMATURE DEMISE of 46-year-old Kannada actor Puneeth Rajkumar due to a heart attack in late October has raised uncomfortable questions about extreme workouts in non-sporting professions that often celebrate taut bodies as a mark of career success. Transforming oneself into a lean, mean male with a wiry, striated physique is the holy grail for those in entertainment and a preoccupation with corporate honchos, most of whom are typically known to sleep less, starve, work more and work out like there is no tomorrow. In such high-stress, high-visibility jobs, the struggle to fit in often means flaunting a perception of being fit and rocking. Some others are keen to build a bulky superhero frame and gorge on protein like the Hulk.

Everything is hunky-dory until news headlines announce that yet another relatively young gym nut has fallen dead in a phenomenon that doctors describe as “sudden death”, which is caused by a myocardial infarction or, in layman’s terms, a heart attack. Dr KK Narayanan Namboodiri, a professor at Thiruvananthapuram’s Sree Chitra Tirunal Institute for Medical Sciences and Technology and a cardiologist well versed in electrophysiology, the branch that studies the heart’s electrical system and diagnoses abnormal heartbeats (arrhythmia), says sudden deaths are those in which a person dies within one hour of the occurrence of “a cardiac event”.

“Unaccustomed exercises trigger a fight-and-flight response and there is an adrenaline surge in people. In the process, their heart rate rises rapidly and dramatically. Usually, people in competitive sports and professionals such as pilots are tested for their endurance levels. Not necessarily gym rats. Basically, these deaths are due to rhythm disturbances in the heart,” Namboodiri explains.

In a peer-reviewed study titled ‘Global Burden of Sudden Cardiac Death [SCD] and Insights from India’, Hyderabad-based cardiologist and electrophysiologist Dr B Hygriv Rao had warned as early as 2014 that not only are the number of such deaths rising in India due to a raft of factors, including change in lifestyles, stress and peer pressure, but there is also an economic burden associated with such events. He wrote, “a clearly visible distinction of the SCD cohort from India compared to the western world is the predominance of economically productive younger population, which is a matter of concern.” That is, in India, those who die such deaths include a large chunk of high-earning and often crème de la crème of society. Even earlier, as early as 2001, Dr Salim Yusuf, known for his pathbreaking studies in cardiac disease prevention, and others had warned about the heart-disease scourge in India and called for collection of data from across the country to devise ways to control it.

SCDs are on the rise in India, especially after Covid-19. And this is also in line with worldwide trends. More than half of all heart disease fatalities in the US are due to SCDs. Dr Rao has himself attested to witnessing many cases of young people in their early 20s with no risk of heart ailments suffering SCDs while recovering from Covid-19. While data about such deaths are not comprehensive, heart attacks and SCDs have seen a spike over the years in India, and SCDs account for a large number of those who die from cardiac events in the country. A 2016 study titled ‘Sudden Cardiac Death in South India: Incidence, Risk Factors and Pathology’ by researchers at the University of California, Davis and Tamil Nadu’s Tirunelveli Medical College found increased risk of SCD among relatively young men in their productive years in the region compared with developed societies.

At the peak of his career as an actor, producer, TV personality and a singer, Puneeth Rajkumar was known as a fitness freak. Son of the late matinee idol of the Kannada film industry Rajkumar, he had started as a child actor and later went on to star in close to 30 movies in Kannada in the lead role. Gripped by the idea of masculinity, he insisted on performing his own stunt scenes. Fondly called Appu, he was also known as the “power star” of Kannada films for his tough build. One of the highest paid in the Kannada film industry, this fifth and youngest son of Rajkumar epitomised the brawny hero in that part of the country. Notably, his family had a history of heart attacks. While his father passed away due to one in 2006, his older brother Shiva survived an attack in 2015.

The death of this popular south Indian actor, known for his philanthropy, was received with disbelief by his fans and others alike. His funeral was attended by more than 25 lakh people.

The situation, says Dr Ashok Seth, is no different in the rest of the country. Seth, chairman of Fortis Escorts Heart Institute and head of Cardiology Council of Fortis Group of Hospitals, avers that most sudden deaths occur due to underlying health issues. “The problem is that people assume that they are fit. Strenuous exercises, when not done in a gradual manner, can lead to such tragedies. Yes, one can prevent it through tests and medical investigations. Echocardiogram and treadmill test are usual ways to check whether someone can actually do extreme training. Even then, it is advised to progress gradually or exercise moderately when people are 40-plus,” he tells Open. Military presses, squats, deadlifts and barbell bench presses are all fine when done in moderation and with light or medium weights, or intensified gradually.

Sudden deaths are common among people with hypertrophic cardiomyopathy (HCM), which Mayo Clinic describes as a disease in which the heart muscle becomes abnormally thick (hypertrophied). “The thickened heart muscle can make it harder for the heart to pump blood. Hypertrophic cardiomyopathy often goes undiagnosed because many people with the disease have few, if any, symptoms and can lead normal lives with no significant problems. However, in a small number of people with HCM, the thickened heart muscle can cause shortness of breath, chest pain or problems in the heart’s electrical system, resulting in life-threatening abnormal heart rhythms (arrhythmias) or sudden death,” Mayo Clinic says.

Electrolyte imbalance also contributes to SCDs when people lose essential minerals during extreme exhaustion. Existing health issues and risks such as hypertension, family history, diabetes and so on can also result in sudden deaths when the electrical system in the heart becomes irregular. The most common life-threatening arrhythmia, according to medical studies, is ventricular fibrillation; it is caused by erratic electric impulses from the heart’s lower chambers. Besides, aortic stenosis, which the American Heart Association explains as “narrowing of the aortic valve opening”, occasionally results in sudden deaths, especially during or after extreme exercise. Myocarditis, inflammation of the heart muscle due to viral infection, is also a cause. Such inflammation reduces the heart’s ability to pump blood and leads to abnormal heart rhythms. The cases of myocarditis among the young and even athletes have seen a spurt due to Covid-19.

A 2020 study titled ‘Recognizing Covid-19-related Myocarditis: The Possible Pathophysiology and Proposed Guideline for Diagnosis and Management’ by researchers in the UK and the US says, “Its pathophysiology likely is a combination of the direct viral insult [injury] to cardiomyocytes [cardiac muscle cells] and the human’s immune response to virally infected myocardium.” A 2021 study titled ‘Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes with Recent SARS-CoV-2 Infection: Results from the Big Ten Covid-19 Cardiac Registry’ found prevalence of myocarditis among Covid-infected athletes in select universities in the US. It said, “Myocarditis is a significant risk factor for SCDs in athletes, especially at younger ages. In an autopsy study of US Air Force recruits with SCD, physical activity was a risk factor, and the most common suspected underlying factor was unrecognised myocarditis. In another study, lymphocytic myocarditis was a common cause of ventricular arrhythmias. Several studies have shown that physical exertion leads to worsening disease and eventual death in mouse models of myocarditis.”

Dr B Soma Raju, one of India’s noted cardiologists, along with former President APJ Abdul Kalam, developed the country’s first indigenous coronary stent, the “Kalam Raju stent”. He tells Open that strenuous exercise is harmful even for healthy people. “Worse is that some people in competitive sports and films look for various types of ‘formula’ food to lose as well as gain weight in California and such places. Such food causes enormous damage to the body as does extreme exercise, especially when done after a gap [like the one after the lockdown],” says Raju emphasising that weight training is good for the body when light weights are used. He however adds that he doesn’t see a spurt in sudden deaths caused by the fad for extreme fitness and dieting. “They are being recognised more now. Such deaths have always been there. Now, one must test well to ensure whether one is capable of strenuous exercises. Even if someone is fit for that, my advice is to exercise moderately,” Dr Raju notes. He also suggests that “celebrities in India need health education. They must read the right literature and hire proper advisors to manage their health and weight.”

Most of these figure fanatics are always in a tearing hurry to look toned and tough. Dr S Harikrishnan, cardiologist and professor at Sree Chitra Tirunal Institute, tells Open that a major exercise regimen must be preceded by systematic preparation. In 2020, he led a pioneering study funded by the Indian Council of Medical Research (ICMR), involving over 10,000 people, that revealed that heart patients in India die 10 years earlier than those in the West due to factors such as inordinate delays in hospitalisation soon after the heart attack that finally result in premature heart failure and death. Dr Harikrishnan had also said that ischemic heart disease was responsible for 70 per cent of heart failure cases and that valvular heart diseases, including rheumatic heart diseases, also contributed to India’s heart ailment burden. According to the US’ National Center for Biotechnology Information, ischemic heart disease is caused by narrowed arteries that supply blood to the heart muscle. “There is no substitute for getting a medical evaluation, especially when there is unease after working out aggressively,” he says.

Blame is increasingly being laid at the door of Covid-19 and the lockdown, too. Not always for the wrong reasons. Dr Raju believes that residual effects of long Covid could also result in inflammation of the heart and resultant complications. “Long Covid” describes the effects of Covid-19 that continue long after the initial illness. According to the US Centers for Disease Control and Prevention, long Covid comprises a range of symptoms that can last weeks or months after first being infected with the coronavirus, or can appear weeks after infection. “Long COVID can happen to anyone who has had COVID-19, even if the illness was mild, or they had no symptoms,” according to the centre.

Some others like cardiologist Haider Warraich are more forceful in airing their opinions. Writing in the New York Times in August 2020, Warraich, the author of State of the Heart: Exploring the History, Science, and Future of Cardiac Disease, said, “myocarditis is not the only way Covid-19 can cause more people to die of heart disease. When I analysed data from the Centers for Disease Control and Prevention, I found that since February nearly 25,000 more Americans have died of heart disease compared with the same period in previous years. Some of these deaths could be put down to Covid-19, but the majority are likely to be because patients deferred care for their hearts. That could lead to a wave of untreated heart disease in the wake of the pandemic.” He argued that data showed that some of the coronavirus’ most potent damage is inflicted on the heart. A 2021 study by researchers in Israel and the US titled ‘Myocarditis after Covid-19 Vaccination in a Large Health Care Organisation’ surveyed the largest healthcare organisation in Israel and found the highest incidence of myocarditis was reported in patients between 16 and 29 years of age. The study suggested that people had higher risk of developing heart issues after taking two doses of Pfizer and Moderna vaccines.

Not all are convinced about claims that Covid-19 or vaccines for it cause heart inflammation. Robert M Sapolsky, professor of neurology and neurological sciences at Stanford University, tells Open “Regarding Covid, I don’t think anyone knows yet with much confidence, but I would not be surprised if there turns out to be long-term, increased vulnerabilities due to chronic inflammation,” he says. “To my knowledge, typical causes [of sudden deaths] are an underlying and undiagnosed medical vulnerability—for example, a congenital weakness of the walls of cerebral blood vessels making the person at risk for an aneurism [an abnormal bulge in the wall of a blood vessel],” he adds.

A section of doctors cautions against moralising about gym enthusiasts. They agree that extreme fitness enthusiasts should subject themselves to health evaluations for their own good.

Dr Ambarish Satwik, a vascular and endovascular surgeon at Delhi’s Sir Ganga Ram Hospital, says it is common in most advanced countries to stratify and classify people before they engage in competitive sport or extreme workouts. “I am not here to dissuade anyone from going to the gym, but risk assessment prior to that saves lives,” he says. Satwik suggests, for instance, besides other tests, an ultrasound of the carotid artery before embarking on a major workout regimen. It is typically intended to check for early stages of atherosclerosis, a disease in which arteries and blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick. He advocates a commonsense approach to life. Dr Raju prescribes similarly: “The key to happy living is moderate exercise and moderate eating. Extreme exercise is not good for any human, no matter which race.”

But commonsense seems to have left the building. Steroid use is rising among the youth to sustain their “Greek God” or “warrior” physiques amid encouragement from gym trainers trying to get their clients hooked.

This is not what the doctor ordered.

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