How Exercise Changes the Heart with Dr. Sonia Tolani

Faith: Hi, Faith here. This week’s episode is hosted by Courtney Allison, a managing editor for New York Presbyterian. Courtney has a fascinating conversation with a sports cardiologist, who explains what exercise does to the heart — and specifically what the heart of an elite athlete might look like. 

Welcome to Health Matters, your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Courtney Allison. 

We all know that exercise is good for the heart, but what happens when you exercise a lot? What does an athlete’s heart look like? Dr. Sonia Tolani, a sports cardiologist at NewYork-Presbyterian and Columbia, discusses how exercise changes the heart and how doctors help assess heart health of competitive athletes. Dr. Tolani also explains how she is taking her own heart health seriously by training for the New York City Marathon.  

Courtney: Hi, Dr. Tolani. So thank you so much for being with us today.

Dr. Tolani: Thank you so much. Thanks for having me.

Courtney: So we’re here today to talk about sports cardiology and what makes an athlete’s heart different, but I understand you’re a bit of an athlete yourself and training for the New York City Marathon. Can you tell us about that?

Dr. Tolani: I am, I am training for my first marathon. I’m a late-in-life, slow runner, but I’m using it as a way to kick off my middle age fitness plan.

Courtney: That’s incredible. So I actually ran it two years ago. I’m also a slow runner and it was one of the best days of my life. So I would love to hear how your training is going and how you think about your heart as you embark on this accomplishment.

Dr. Tolani: You know, I’ve approached my marathon training as really a way to make time for myself to work on my own personal fitness to get me set up going into my 50s, 60s, 70s as a more regular exerciser. Unless you’re an elite athlete, we’re all just out there to get our participation medal, right? We’re all just out there to do our personal best. 

And right now I’m at that point where I’m like, am I gonna be able to do it? I’ve had a couple injuries. I fell. I was ill, you know. You take time away from your rigid training plan. But I think at the end, no matter what I’m in the best shape that I’ve ever been in my life, and that feels really good for me.

Courtney: Absolutely. Well, you’re inspiring me to get back to running and prioritizing exercise and good luck. I’m going to be thinking of you so much on marathon day. That’s very exciting.

Dr. Tolani: Fingers crossed.

Courtney: So the training you’re doing is “cardio.” Can you explain what “cardio” is and what kind of exercise is good for your heart?

Dr. Tolani: We consider cardio any sort of aerobic exercise, you know: walking, jogging, playing basketball, playing tennis where you’re kind of moving all of your parts. You’re getting your heart rate up and we classify exercise and three major categories, mild effort, moderate effort, and vigorous effort.

So moderate effort is what we’re trying to go for for heart health. That’s a level where you could have a conversation, but you couldn’t sing a song. And then a vigorous effort would be where it would be hard for you to have a conversation, but you’re not dizzy or lightheaded. And those are the exercises that we target for cardiovascular fitness.

So and that’s to distinguish it between sort of strength training. You know strength training is going to be more your weight lifting, you know, Pilates, yoga, things that are working on your core your body strength, your stability.

And those are very important for a lot of aspects of your health. But when we talk about heart health, we’re often focusing on that aerobic, you know, raising your heart rate type of exercise.

Courtney: And so today in addition to the everyday athlete, we also want to get into what happens to athlete hearts. People who do more than moderate exercise, right? So the big picture, what makes sports cardiology different from the other work that you do?

Dr. Tolani: Well, you know, there’s a lot of different types of sports cardiologists. At NewYork-Presbyterian , the real focus of our sports cardiology program is helping to sort through issues that may come up in a athlete’s training that would help distinguish whether they’re safe to continue to exercise or they’re not safe to continue to exercise, assessing their risk and trying to determine if whether some of the quote unquote abnormalities that might be noted on a cardiac test is normal for an athlete or something that needs to be addressed.

So going back to the concept of two types of exercise, right? So we have more of an endurance athlete. That’s going to be your rower, your runner, you know, where it’s really cardio the bulk of the time versus a strength training athlete and that’s going to be more like your power lifters, you know, where it’s really a lot of strength and short bursts of powerful activity rather than a long sustained and then there’s mixed sports.

So maybe we would throw in basketball as probably an endurance sport, but it has some strength properties so there’s some sports that sort of lie in between. Different types of athletes and we’ll have different cardiac remodeling. So the heart does change with regards to the type of exercise we’re doing and we’re talking about elite athletes. And what happens for an endurance athlete is because the cardiac output that they need increases so much. Their heart can actually grow in size. It can be bigger.

Courtney: Wow.

Dr. Tolani: Their heart rates often are much lower, and those are all parts of the athletic changes that would be normal. Now, a power athlete such as say, like a power lifter, what happens in that type of sport is because it’s a load that you’re pushing against all the time, the muscle of the heart can get thicker, just like any other muscle in your body. And those two different types of remodeling, depending on the sport, can be normal. 

There are some changes and there are some differences that we know, but there’s a point where if athletes go beyond that, we do have to do our due diligence to make sure that there’s not something else going on with them.

And that’s where we delve into additional cardiac testing, sophisticated testing, like cardiac MRI. We delve into family history. We look at other types of tests to come up with whether or not this is an athletic change or whether or not this is a cardiac problem.

There are going to be people who we will, unfortunately, find to have, you know, very serious heart conditions that they’ve inherited that, based on their risk, we do think it’s not, safe for them to continue to play at an elite level, 

And I think then there’s a majority of people are moving into this discussion with the athlete, and saying, hey, listen, you have some abnormality. The best that we could tell you is that you’re at higher risk than if you didn’t have this. But we don’t think your risk is so extreme that we would tell you not to play, you know? Do we have that life or death decision with people every day? No, but that’s part of what we do in sports cardiology.

Courtney: So let’s talk more about the screenings that you do, that give people these information to have these conversations. You describe when you’re doing a screening, what are you looking for and what kinds of things do the results tell you?

Dr. Tolani: The risk of sudden cardiac death in athletes is actually very low. You know, it’s dependent on the sport. Ethnicity, there’s other things that go into it, but overall it’s exceedingly low, but obviously nobody wants it to ever happen, right? but the issue is what are we going to be able to identify on that screening to prevent? 

So depending on different leagues, different levels, there may be certain screening involved or not. What we recommend for every sports physical is a 12 point questionnaire where we go through very specific things, family history, do they have symptoms? Have they ever fainted? There’s certain features on the physical exam that we look for. So that, that questionnaire might be the only screening process at a, at a college or a high school and any positives may then lead to an EKG. Every league has its sort of own, screening protocol. 

Courtney: Hm.

Dr. Tolani: And if you look at the causes for sudden cardiac death in athletes in different studies, it varies widely depending on the population that they’re looking at, the age, the type of sport,

Courtney: Hm. Mm hmm.

Dr. Tolani: They’re gonna be, as I said, right, there’s some athletic changes that may happen, right? If you’re not a sports cardiologist and you look at an EKG, you’re gonna be like, that looks crazy,

Courtney: So is this cardiac remodeling to the heart? Is it the kind of thing that might happen to other muscles when we exercise them say with lifting or calisthenics?

Dr. Tolani: It’s not just like, you know, if I start lifting weights, my biceps going to get bigger. It’s not as simple as that. It has to do with amount of blood flow and your cardiac output, which is determined by your heart rate and how much blood you’re pumping and what type of sport you’re doing. 

I mean, look in the news at some of the athletes, like, I know these athletes in these leagues have been screened, right? But there’s still things happen. They were not picked up, obviously, on a screening. They, we don’t know what the cause of it was.

It could be, like, a cardiac anomaly that may not show up on some of these tests that we do. But if we have a good emergency response, we know how to deal with an event on the field. 

Courtney: Can you tell me what that looks like? Can you talk about that emergency response? Mm hmm.

Dr. Tolani: So, we recommend, um, and again, every single professional league, each team, and in the colleges that we take care of at NewYork-Presbyterian, Each college, university, should have an emergency response plan. And that response plan includes knowing what to do, having the equipment, and having trained personnel. I think having defibrillators available at all the games is really important. Now, not all programs are going to be resourced to do that, but I think that’s, that is an ideal situation. What determines whether someone survives a cardiac arrest is how quickly they get resuscitated.

Courtney: Mm hmm.

Dr. Tolani: So hands only CPR can buy time until a defibrillator comes. So really good hands only CPR and having everybody, everybody on the team trained to do that. All the PT, all the trainers, all the players, all the people that are going to be part of that staff should be trained. And then the knowing how to use the defibrillator, which is really easy, and having it on hand.

So sometimes you see these videos and it’s terrible and everybody’s running around in circles. You know what I mean? And it’s because they haven’t practiced that because you have to practice too. So part of the emergency plan is having regular practices just like anything else. You got to have a drill to run through it.

To be honest, all of us should know CPR, you know? Because this could happen on a plane. This could happen at a family event. You know what I mean? It’s such an easy thing, hands only CPR, and that’s, that just buys time until equipment can come.

Courtney: Yeah, I can save lives.

Dr. Tolani: Absolutely. 

Courtney: Dr. Tolani, this has been such a wonderful conversation and it’s been so insightful learning about athletes and how their hearts may be different. And good luck to you on your run coming up in a few days!

Dr. Tolani: Thank you. This has been great.

Courtney: Our many thanks to Dr. Tolani. I’m Courtney Allison.

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