Raju Srivastava death: Is over-exertion at the gym damaging your heart? Why a TMT test is not enough?

Comedian Raju Srivastava’s death, after suffering a cardiac arrest and collapsing on a treadmill last month, raises a key question: Should we have a limit on our exercise regimen, and are we taking out fitness mantra to extremes and over-exerting ourselves? Is our obsession with getting lean stressing the heart out? Cardiologs say that 150 minutes of any exercise regime every week are good enough and a longer routine than that does not guarantee extra benefits. In fact, it may do harm than good if the person is already prone to heart disease and suffers from markers like hypertension, anxiety or even a silent blockage that has not harmed him thus far.
“All you need are 150 minutes for five days a week, or 30 minutes of exercise each day. It should be a healthy mix of aerobics, weight training (this strengthens muscles, including the heart) and stretching (yoga and breathing exercises). This rotational regime is good for both physical and mental health. Stop during exercise if you have discomfort and get yourself tested before you adopt any high-intensity regime,” advises Dr Ruchit Shah, Interventional Cardiolog, Masina Hospital, Mumbai.
“Regular exercise increases your heart rate, improves your cardiac muscles and aids in enhancing your lung capacity. On the other hand, there is a phenomenon known as over-exercising. Continual over-exertion has been linked to an increased risk of ‘atrial fibrillation’, a form of irregular heart rhythm that can be fatal if left untreated. Besides, it can potentially raise the risk of cardiac abnormalities, particularly for those with hypertrophic cardiomyopathy or coronary heart disease,” says Dr Shalin Thakore, Senior Interventional Cardiolog, Shal Hospitals Ahmedabad.
What is Hypertrophic Obstructive Cardiomyopathy?
Hypertrophic cardiomyopathy, usually caused genes, is when the walls of the heart chamber (left ventricle) become thicker than normal. The thickened walls may become stiff and this can reduce the amount of blood taken in and pumped out to the body with each heartbeat. The thickened part of the heart muscle, usually the wall (septum) between the two bottom chambers (ventricles), blocks or reduces the blood flow from the left ventricle to the aorta.
“This can provoke sudden cardiac arrest and a patient needs resuscitation in the first 60 seconds. In fact, we must train students in schools and colleges about CPR. All of us should know how to adminer this. Besides, every public place should have defibrillators, schools and college students,” says Dr Shah.
THE PRE-GYM MUST-DOS: NOT JUST A TMT TEST
Dr RR Kasliwal, Chairman of Clinical and Preventive Cardiology at Medanta hospital, Gurgaon, advocates a full cardiac work-up for any person going to the gym or doing any strenuous activity. “Just a TMT (treadmill test) doesn’t cut it. These days there are CT angiographies that can tell even if there is a 40 to 50 per cent blockage. Such a blockage would not show up on TMT because there is not much impairment in the patient’s capacity. Always know your heart before you take up some strenuous activity. Many people who get cardiac arrest do not live to tell the tale.”
He said the same should apply to anyone who stopped working out during the pandemic and is now resuming an old routine. Such check-ups are particularly essential for diabetics and women, he said, because they might not experience a heart attack as a typical pain in the chest.
Dr Kasliwal said that the Covid-19 status of the patient is also very important. “If you have had Covid-19 — and we know now that long Covid-19 is leading to sudden cardiac death — it is very important that you check your heart health. Those who have had Covid-19 also have high heart rate (tachycardia) sometimes.”
Intensity and duration act as critical factors“When treadmill is done at very high speed and /or inclination, there is a double impact, that is the heart rate and blood pressure, which is a determinant of the oxygen demand in the heart. High mets (metabolic equivalent) during higher speed and for prolonged periods can cause undue stress on a compromised heart circulation in a setting of heart blockages. They cause sudden arrhythmia, undue low blood pressure or a heart attack. Such people need to be evaluated urgently with coronary angiography and should have appropriate revascularisation, for example, stenting procedure as per current guidelines,” says Dr Suman Bhandari, Visiting Consultant, Interventional Cardiology, Fortis Escorts Heart Institute.
Vigorous activity makes you breathless and sweat heavily. Go for moderate-intensity workouts instead, which comprise activities that increase your heart rate, such as casual sports, brisk walking, jogging, cycling, and swimming. “Every individual must engage in 30 minutes of moderate-intensity physical activity on a daily basis in order to receive the health benefits. One must avoid testing their physical strength and physique. Whether you are a novice or a seasoned exerciser, you should not overdo it. In addition, allow sufficient time for your body to recuperate and mend. Consult a doctor if you experience any difficulties,” adds Dr Thakore.
How to prevent over-exertion?
Exercise has both direct and indirect beneficial effects on the heart. Direct effects include, helping the heart muscles get stronger and pump more blood per heartbeat as well as the ability to withstand abnormal heart rhythms better. Indirect effects include beneficial effects on blood pressure, sugar, cholesterol, and body fat, all of which reduce the chances of a heart attack.
“It is important to keep in mind that sudden cardiac death very rarely occurs in someone with a healthy heart. Exercise may be the trigger to have a cardiac event in individuals who have undetected or silent heart disease. In terms of a single episode of exercise, there is no absolute upper limit defined, and it all depends on the individual’s training level. One should avoid high levels of unaccustomed exertion, the rule of thumb being that any given bout of exercise should not be more than a ten per cent increase compared to previous bouts. Environmental conditions should also be considered, and outdoor exercise should be avoided in extreme weather conditions; as this is one scenario where even a healthy person could suffer serious consequences,” says Dr Aashish Contractor, Director, Sports Medicine and Rehabilitation, Sir H N Reliance Foundation Hospital, Mumbai.
He adds that “Another way to look at ‘too much exercise’, is the overall volume of exercise accumulated over the years. Here, the research has shown that a very large volume of exercise over several decades might cause some changes in the heart muscle, as well as accumulation of calcium in the coronary arteries. At this point, the amount of exercise has not been defined, and the consequences of these changes have not been fully understood. However, it is well known that to reap optimum health benefits, moderate exercise is the way to go. So how does one reduce the risk? In my opinion, risk can be reduced taking care of the following:1. Pre-participation health check2. Paying heed to warning signs3. Sensible and appropriate training programmes.”
Balancing fitness routine with a healthy diet
Indians are genetically prone to developing heart disease 15 or 20 years earlier than their Western and Japanese counterparts. And since our genes are not modifiable, we have to look at modifiable factors like lifestyle, sleep cycles and stress. “Now stress is compounded tobacco, tobacco-derived products and alcohol. Did you know that the effect of even a single tobacco use lasts for three to six months? rough estimates, a cigarette shortens your life five to seven minutes. Which means a moderate smoker can easily reduce his/her life three to five years. Instead of ‘no smoking’ banners, we should start a ‘why you should not start smoking’ campaign,” says Dr Shah.
Maintaining physical and mental health requires a good diet and regular exercise. “When people conduct high-intensity workouts and consume less, the body uses nutrition reserves, causing deficits. Following fad diets to lose weight promotes starvation, anaemia, heart disease, stroke, poor mental health, etc. Align your diet with your workout regimen. Choose healthy carbs as they power one’s brain and body. Carbohydrates recharge the body after a workout. Eating quality proteins post-workout repairs muscle microtears and boosts blood flow. Some fats are actually healthy despite being calorically dense. Polyunsaturated fat is advantageous. One can also look for sunflower oil, soybean oil, and various nuts and seedsas they contain omega fatty acids. In conclusion, the benefits of exercise should not be called into doubt; on the contrary, they should be reinforced. However, moderate activity and a healthy diet are strongly affirmed for a healthy heart,” says Dr Thakore.
Dr Shah advocates the “Ek chamach kam (One teaspoon less)” campaign, which entails cutting down on our use of the three whites in our food — salt and sugar and oil. More fruits and vegetables. Minimise cakes and junk foods.”
When should you get tested for cardiac fitness?
Coronary Artery Disease (CAD) can start as early as your teen years. Plaque can form that early. “To prevent further build-up, your first BP, sugar test and lipid profile test should be done at age 18 and then once every three to four years. Do check your BP during every clinical visit. You need to do the ECG once a year when you turn 40 and depending on your other parameters, space out the frequency as advised your doctor. Watch your LDL levels and for those who have not undergone intervention, maintain the level at less than 60 mg/dL less and for those with cardiac intervention like stenting, less than 30 mg/dL,” advises Dr Shah. No test is foolproof. What we need is a good alertness level.
UNDERSTANDING PLAQUE RUPTURE
Explaining these sudden episodes, Prof K. Srinath Reddy, a cardiolog, epidemiolog and president, Public Health Foundation of India (PHFI), says, “Chronic obstruction of 70 per cent or more in a coronary artery produces angina or chest pain on exertion, since available blood supply does not meet the increased oxygen demand of the exercising body and straining heart. However, a heart attack (acute myocardial infarction) can occur when soft plaques that form in the coronary arteries rupture and cause a large clot to form. This may come without any prior warning symptoms. Even plaques of 30 per cent can rupture and set up the formation of a large obstructive clot.”