The six vigorous, middle-aged professionals exercised for all the right reasons: to relieve stress, reduce blood pressure, and condition their hearts and lungs. To live longer.
So why did they die?
It's a question that friends, relatives and even doctors are asking after the recent heart-related deaths of four physicians, an insurance executive and a tax adviser.
What perplexes many is that the Baltimore-area men, all seemingly healthy, died during or shortly after workouts they thought were keeping them fit. Though the cases are different and raise imponderables about exercise and health, doctors struggling to make sense of the deaths say there are some important lessons.
One is that baby boomers are entering an age of increasing risk for heart attack and should assess their health before starting a program of heavy workouts. Exercise is one of the great protectors of the human heart, but it can also aggravate an underlying condition - sometimes with fatal consequences.
The string of deaths took on an eerie cast late last month when two physicians in their 40s - Dr. Michael Gallagher of St. Agnes HealthCare and Dr. Frederick J. Montz of Johns Hopkins Hospital - collapsed and died within a few days of each other while jogging.
Montz's death Nov. 21 occurred exactly seven months after Dr. David Nagey suffered a fatal heart attack while running in a 5-kilometer fund-raiser for the Crownsville school where his wife worked. Both doctors worked in the Hopkins department of obstetrics and gynecology.
"Here are individuals who did everything right, were out running and then they're dead," said Dr. Harold E. Fox, the OBGYN director. "For me, it's very difficult to grasp why this happened. The grief here is profound."
Montz was actually the third Hopkins physician to die while exercising since April. A month after Nagey died, Dr. Jeffery Williams, a neurosurgeon who devised a novel way to treat brain tumors with radiation, died of a heart attack while working out in the hospital's fitness center. He was 50.
Cardiovascular disease, a category that includes heart disease and stroke, remains the leading cause of death in the United States - claiming almost 1 million lives each year, far more than cancer. About 22 percent of adults in their 40s have some form of cardiovascular disease, but the percentage doubles among adults in their 50s.
While exercise can prevent a heart attack in the long run - reducing cholesterol, blood pressure, body fat and the risk of diabetes - it can also trigger one in a heart compromised by disease.
"It is true that, overall, people who exercise on a regular basis have much lower risk than the average person," said Dr. Roger Blumenthal, who heads preventive cardiology at Hopkins. "But during the time they are exercising, their risk of having a problem is increased."
Vigorous exercise poses the greatest immediate threat to people who have certain factors. Surpassing all others is a family history of heart disease, particularly a parent or sibling who suffered a heart attack or symptoms at a relatively young age. Other potential risks are smoking, diabetes, hypertension and high cholesterol or other bloodstream fats.
Anyone who has these problems or symptoms such as chest pains, shortness of breath or fatigue should consult a doctor before exercising strenuously, doctors say. Heart attacks are caused by plaques in the coronary arteries that can rupture and clot, blocking blood flow and provoking irregular heartbeats.
Exercise "may be stressing a heart that already has a blocked artery," Blumenthal said. "When the heart is beating very quickly, there is a small increased risk of a plaque rupture. If an artery blocks off, it's unclear whether the heart may be able to compensate."
Traditionally, doctors have assessed the risk of a blockage by testing cholesterol, blood pressure and a person's endurance on a treadmill - called the stress test. Now, doctors are also turning to high-tech measures such as an ultra-fast CT scan, which can detect calcifications that are a key ingredient of plaques.
Such tests can pick up a subtle problem that can be easily treated with aspirin or cholesterol-lowering drugs. People with blocked arteries can often be treated with stents, mesh sleeves that reopen an artery and restore normal blood flow.
No rules on exercise
Doctors say there is no rule on how much exercise a patient who has been treated for heart disease can tolerate, though they agree that exercise is a key to recovery.
"You should probably be able to do whatever you want to do if you've been properly evaluated and re-vascularized," said Dr. Stephen Pollock, a St. Joseph cardiologist who received two stents last year and performs aerobics and weight lifting five days a week.
Pollock, who is 50, learned he had a problem through a stress test. Though he had no symptoms, he got tested because his father died of a heart attack at an early age.
