stanford medicine


The ultramarathonerís heart - Code blue on the running trail

Special Report

The ultra-
marathonerís heart

Code blue on the running trail

On Labor Day 2011, Mike Nuttall ran up a dusty trail in the golden foothills above Silicon Valley. It was a clear, hot morning that smelled of burnt grass and roasted acorns. One thousand feet below, glassy tech buildings shimmered like a diamond necklace around the San Francisco Bay.

Slightly rumpled with bed-head blonde hair, Nuttall, 62, looked a bit like an aging rock star. Thirty years earlier, he joined the “British invasion” of industrial designers who came to Silicon Valley to define the physical design of the first personal computers.

During that time, like so many California immigrants, he reinvented himself. He quit smoking and excessive partying. And he became an ultramarathoner, one of those superhuman-endurance freaks who run 100-mile races.

As Nuttall headed down the trail, his training partner, Bert Keely, noticed that he was in pain.

“Mike started popping Rolaids,” says Keely. “He was dead tired. His face was chalk white.”

Indigestion, Nuttall figured, and he kept running.

An ultramarathon pushes a body to its outer limits. Bones and joints are pounded. Dehydration can upset the electrolyte system, the delicate balance of salts and fluids that regulates heart, nerve and muscle functions. The heart, the ultramarathoner of organs, goes into overdrive for about 24 hours. But above all, an ultramarathon tests the mind, as a runner strives to override the brain’s overwhelming signals of pain and fatigue.

On this Labor Day, Nuttall’s laboring heart was telling him to take it easy, but he kept running. Sure, he had experienced some minor chest pain on other runs. But his physician had given him a stress test just a few weeks before and had said his heart was fine.

At the bottom of the trail, where Nuttall’s wife, Jan, met them, Nuttall was obviously in agony. Keely insisted that Nuttall let Jan drive him to the emergency room — where Nuttall was immediately scheduled for heart bypass surgery. He had just had a heart attack.

And while most post-heart-attack patients might ease back into exercise after major surgery, this ultramarathoner wasn’t a typical patient. A few days later, he formulated a recovery plan that would put his surgeon’s repairs — and his friend’s loyalty — to the ultimate test.

Nuttall was a born-again athlete who didn’t start running until age 40.

 “As a child, I never exercised,” says Nuttall. “I couldn’t catch or hit a ball. I was always the last kid picked on the playground.”
In his hometown of Manchester, England, where real men all play soccer and cricket, Nuttall was an outcast. In grade school, he would forge sick notes from his mother to avoid the embarrassment of ball sports days.

While his mates were on the field, all his drive and energy were channeled into drawing and design. So when it came time for college, he decided to study painting at the Leicester College of Art & Design.
“I was good at Leicester’s sports — darts and drinking.”

He soon found himself drawn to industrial design, the art and science of improving the aesthetics, human factors and usability of products. He developed a preference for sleek and simple design, perhaps because he grew up with a father who designed airplane wings.

Next, while attending the Royal College of Art in London, he met legendary British designer Bill Moggridge, who recruited him to build models for his small design firm.

Moggridge was quick to see the business opportunity in bringing the European design aesthetic to Silicon Valley. And in 1979, around the time that Steve Jobs was stuffing his first circuit board inside a box that looked like a high school woodworking project, he opened an office in Palo Alto and brought Nuttall over to help. (Later, Moggridge and Nuttall would join David Kelley to found IDEO, the famous design think-tank. They also taught design classes at Stanford.)

The Moggridge-Nuttall team had an immediate impact on Silicon Valley product design. In 1982, both designers worked on the Grid Compass, the first clamshell laptop computer, and the first Microsoft mouse. Nuttall took the design lead on the first tablet computer, WorkSlate, from Convergent Technologies and teamed up with a relatively new engineering graduate from Stanford, Keely, his future running partner.

Together, Nuttall and Keely worked together on the WorkSlate tablet to raise the bar for truly portable computer design on a number of fronts. While IBM’s first personal computers were housed in boring beige plastic boxes the size of a small suitcase and tethered to electrical outlets, the portable WorkSlate had the footprint of a piece of notebook paper and was less than an inch thick. It was sleek, black and sophisticated, with round, dimpled keys and an embedded LCD screen. During the long days and nights of work on project, Nuttall and Keely realized that they both had a shared a love of minimalist product design and excessive distance running. In subsequent years they began training together.

Unfortunately this revolutionary tablet computer, perhaps a bit too ahead of its time, failed in the marketplace. And just as Nuttall was finishing up this project, his father died of a heart attack, at age 56. Though Nuttall claims this unexpected death didn’t have a big effect on him, he says, “I realized I wasn’t immortal.” And for the first time in his life, he started running, in the same way he pursued design — with obsessive intensity.

Upon hearing about Nuttall’s heart attack, Euan Ashley, MD, a cardiologist at Stanford, wasn’t surprised to learn the runner had a family history of heart disease.

 “There’s probably a genetic factor at work,” says Ashley, with a Hogwarts Academy kind of boyish charm. Ashley first became interested in hearts while studying medicine Glasgow, Scotland, a European hot spot for heart disease.

As director of the Stanford Center for Inherited Cardiovascular Disease, Ashley routinely uses genetic information in the diagnosis of his patients. Through the genetic analysis of identical twins with heart disease, researchers know that up to 50 percent of heart attacks can be attributed to genetic factors. Ongoing work at Stanford is aimed at identifying the actual genetic variants involved.

When asked what plaque is made of, he replies, “A lot of badness.” This “badness” is mostly comprised of cholesterol, a fatty residue that accumulates over years.

Though there is still more research to be done, his dream is that someday routine genetic tests will motivate patients to take corrective actions well before they result in catastrophic failures.


“As early as age 12, fatty streaks of cholesterol begin forming on the insides of arteries,” says Ashley. He pulls out a sheet of blank paper and begins sketching a cross section of an artery blocked with cholesterol, which over time becomes hard and crusty.

He explains that contrary to popular misconceptions, heart attacks aren’t caused by the cholesterol clogging the pipes. Rather, a heart attack is triggered when the cholesterol lining inside an artery cracks and releases a tissue factor that tells the body that there could be a dangerous rip in an artery. This initiates a blood clotting process that starves the heart of oxygenated blood and induces a cramp that causes pain. When essential heart tissue dies from lack of oxygen, so does the patient.

This begs the question, should someone with genetic heart disease participate in extreme distance races?

“Although there are some people with rare forms of genetic heart disease who should avoid high intensity exercise,” says Ashley, “the thing to remember is that exercise is good for every organ in the body — it reduces your risk of heart disease, lung disease, bone disease and many cancers as well as improving back pain, brain function, immune function and more. You name it, exercise makes it better. We actually see quite a lot of athletes at our center. We always try to strike the balance between the benefits of exercise for the many and the risks of exercise for the few.”

Eswar Krishnan, MD, a Stanford clinical epidemiologist who recently published an observational study of 1,221 active ultramarathon runners, was more cautious in his advice.

“Many may think that just because they are conditioned to run long distances that their hearts may be automatically protected from coronary artery disease,” says Krishnan. “This case illustrates the hazards of such complacency and the principle that sometimes genes may trump environmental and lifestyle factors.”

The first phase of Krishnan’s study, which was published in PLOS ONE on Jan. 8, found that the ultramarathon runners were healthier than the U.S. population on the whole, and that only 0.7 percent of the studied runners suffered from coronary disease.

As Nuttall arrived at the emergency room of Sequoia Hospital in Redwood City, Calif., he told the triage nurse that he had a pain level that felt like “a couch was sitting on my chest.” He was immediately sent to the cardiology lab, where imaging revealed that three of his coronary arteries were blocked 80 to 85 percent with plaque.

“He was clearly in trouble when I saw him, with signs of an ongoing heart attack,” recalls Luis Castro, MD, a Stanford-trained surgeon who is currently director of cardiac surgery at the hospital. “When we couldn’t settle his heart down, we decided that he needed an emergency bypass operation.”

A coronary bypass is essentially a high-priced plumbing job.During his three-hour operation, two of Nuttall’s underutilized chest wall arteries and one leg vein were removed and reattached to reroute blood around the blocked heart arteries. This workaround ensures that his heart receives enough oxygenated blood to keep pumping.

“Nuttall’s case is one of those that you typically first hear about on the obituary page,” says Castro. “Luckily, his had a happy ending.”

Three days after a bypass procedure, a typical patient might contemplate his own mortality and think about a measured plan for resuming exercise. But Nuttall wasn’t a typical patient, and as he sat in his hospital bed thumbing through an ultramarathon magazine, he made a decision — he was going to run a 100-mile race in the Himalayas within a year.

 “I almost signed up before I left the hospital … but decided that this might seem a bit reckless,” says Nuttall.

When Keely heard about the plan, he insisted that Nuttall get permission from his cardiologist first. He was worried that his friend’s stubbornness would override his better judgment. He listed a few examples. There was the time that Nuttall had to drop out at the 93rd mile of the Western States 100 after an electrolyte imbalance triggered a back spasm. And that incident where Nuttall tripped during a 25-mile training run, and Keely had to support him for 10 miles through Desolation Wilderness near Lake Tahoe, Calif.

“We weren’t really paying attention to the trail conditions; it was an unusually bad mosquito year, we were preoccupied with our 500 mosquito welts,” says Keely. “I knew I couldn’t talk him out of Himalayas, so decided to go with him. I couldn’t afford to let something bad happen out there.”

A year after the bypass, Nuttall meticulously prepared for the Himalayan 100-Mile Stage Race. First, he selected four pairs of shoes from the 10 pairs lined up on his front porch.

“The minute you feel a blister, you change shoes as soon as possible,” says Nuttall.

Next, he packed lubricants of various types, medical tape and blister pads, anything to avoid the inevitable chaffing that happens with human body parts over the course of 100 miles of repetitive motion.

He stuffed two headlamps into a fanny pack, since part of the multiday race would be run in the dark. Then he packed an assortment of drugs into a sandwich baggie — allergy pills, an asthma inhaler, ibuprofen for pain, salt tablets and caffeine pills to stay awake during the 24 or more hours of running.

Last but not least, he packed his nitroglycerin pills.

“Look how tiny these are,” he says. “You let one of these melt on your tongue, and the heart pain goes away instantly.”

Nuttall and Keely joined about 60 other runners at the race’s start on the border of India and Nepal. From the trails, they had views of Mount Everest, Lhotse, Makalu and Kanchenjunga, among the top five highest peaks on Earth.

The race would take place over five days, with each day’s run covering 13 to 28 miles and altitude changes of up to 35,000 feet. Each night they would sleep in unheated tin huts with windows that didn’t close.

“I was relieved that the first stage was only 20 miles,” says Keely, thinking that it would be an easy test for Nuttall’s newly refurbished heart. But the relief was only temporary. “It was 24 miles and had ridiculously rugged terrain.”

Trouble arrived two days into the run. The middle of Nuttall’s back started hurting, and he wasn’t sure if it was a back spasm or another heart attack. To self-diagnose, he pulled his small, brown-glass vial of nitroglycerin pills. He let a pill melt under his tongue, and much to his relief, the pain persisted — it was a back spasm, not a heart attack. To help him out, the other runners massaged his knotted muscles and shared advice on pain management.

“The real test for Mike was the next day, the 28-mile marathon leg of the trek,” says Keely. “I was concerned that he might end up in the dark, on terrain that was foreign in every way.”

Keely made sure that he or another runner was at Nuttall’s side at all times. He also made sure that they would know the quickest way to get help from anywhere along the route.

As Keely waited anxiously for hours at the finish line, finally, a half-hour before sunset, he spotted Nuttall. He felt overwhelming relief.

“It was otherworldly,” says Keely. “In the Himalayas, there’s a healing spirit. The people there live on the edge of survival, and they develop a reverence for nature. That was my most vivid memory of the race, the moment I knew that he was going to make it.”

A year later, Nuttall prepared for another 100-mile race to be held on dusty, rugged dirt roads in the Arizona desert. Since his heart attack, he packs one more thing before embarking on his distance races — a Mio Alpha Strapless Continuous Heart Rate Monitor. This sleek, slate-colored monitor looks like a wristwatch, and from a design perspective, it looks like a companion product to the WorkSlate, circa 1982. When he turns it on, optic pads over the wrist measure heart signals. A red light blinks and a chime goes off if his heart reaches a predetermined dangerous threshold.

“I use this to make sure my heart rate doesn’t go too high during the race,” says Nuttall.

As he finishes packing, he talks about how excited he is to run the next big race after Arizona — the Big Sur International Marathon. He calls it “the most beautiful distance race in the world.” He estimates that it will be his 59th marathon-or-longer race, and at Big Sur he hopes to equal his personal best of second place in this age group.

He seems unfazed by his earlier heart-stopping experience. And the impression I get is the new heart monitor is simply a placebo to give his friends and relatives peace of mind. Because, honestly, if something bad happened while doing what you love, running with your best friend, through groves of 1,000-year-old sequoia trees or along Highway 1, overlooking the California’s rugged coastline, that might be okay. There are much worse ways to go.


Contact Kris Newby





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