For me, as a longtime ultra-distance runner who also does strength/mobility at age 57, I’m overall satisfied and feel youthful. The issue I struggle with (but am making peace with) is the comparison trap of comparing myself to how I performed in my forties. I hope I’ll still traverse mountains and my body won’t hurt as I do it in my late sixties. If I can, I want to celebrate that and be in the moment rather than bemoan how much slower I move and how much more rest I need. I’m grateful I still feel motivation for that. Related: it’s an ongoing struggle in my long marriage that my spouse is uninterested in working out, and he’s aging more rapidly. So a limitation for me may be feeling lonely and frustrated that I can’t share my outdoor adventures with my partner because he lacks the physical capability and motivation. I learned long ago that I can’t change him, and our marriage has lasted in part with the attitude “you do you,” and he is fine with how he is and generously supports my sport. But he’s not very healthy, which pains me. I’m sure I’m not the only reader in your health-conscious audience who faces this issue with their partner!
I expect there are a large number of us to live in a similar situation. My wife is older than me (by 6yrs) and has a laundry list of health issues that have drastically ramped up in the past 5 years. And due to those issues, there really isn't much she can do to improve her situation.
I am committed to doing what I can but came to the 'crashing plane' realization - you have to save yourself before you can help anyone else...
I am going to be 78 in September. I am fairly fit as I have maintained a workout of some description since my late 30s. Jane Fonda, running , step workouts, cardio kickboxing. I didn't get serious about weights until my 60s when hiking became my passion and I struggled to do steep climbs. But now, late 70s, I am struggling with arthritic knees, my right hand, my elbows are getting grumpy. My fear is how to keep my fitness level. There isn't much information for women my age. I was so happy to find you because you make so much sense and aren't selling something. However you seem to be geared mostly to men which is fine. Lots of your advice works for both genders. I have modified my workouts. Resting more. Eating more protein. Taking supplements. Knees are biggest problem. My biggest fear is to lose my mobility.
Thanks, Dawn. I don't purposefully pass on advice meant just for men. A lot of the junk science shared about exercise in women is simply wrong. The overwhelming majority of solid clinical evidence is that women need the same types of training that men do, although I do add more jumping and impact loading for women, and most clients over 50 for bone density issues.
That's where confusion arises as there are people who insist training for women isn't the same as for men. I became overwhelmed with it all and just started listening to you and one other male on Substack. Common sense advice. Went back to what I already knew worked for me and got me this far.
1) Even after following your plan (4-5 days a week of Zone 2 run-walking plus one day of HIIT, plus 2 days/week of strength) for about 3 months, I’m still plateaued and not making any progress. I’m 61 so my expectations are low, but still, it’s discouraging.
2). The above-described program is extremely time consuming and it does interfere with other important things that I want to spend my time on.
I’ve been doing this (or something similar) for several years. I’ve been doing light running since I was 48. I do it because my health is important to me. Still, it’s becoming discouraging, the double whammy of not seeing progress while also sacrificing time that I could really use for things that are important to me.
Despite my current (today’s) state of mind, I want to add that I’m very grateful to still be healthy and active, and I do appreciate that all the work I’ve done for years is making that possible. Also, I’m still following your writing because I’ve found it very valuable - a rare source of in-depth but sound advice for my age group - and I appreciate it very much.
I want to learn what I need to continue running, ideally injury-free, and my motivator is always understanding how things work, so I appreciate your thorough explanations. I'm a septuagenarian who has been running several marathons annually for decades. Until recently, I've been of the belief that the best training for running is running. In recent years, though, I've started getting minor injuries and the most effective part of my PT has been the strengthening exercises that target problem areas, so I'm finally appreciating the importance of strength training. (Also I trusted my PT's advice more after reading "Painful Tendons want Load" and better understood how that works.) What I most appreciate about your writing is learning how the body works, and the value of doing (inevitably boring) strength work.
I tore my meniscus and MCL 5 months ago. Recovery has been so painful and slow. I also have arthritis and about 70% cartilage left. I am a 66 yo female and not in good shape before the injury. I have done 3 rounds of PT, PRP injection, steroid injection. None of those helped much and I would argue made me worse. I discovered your stack and have been doing your isometric exercises and am finally getting back to me. Thank you for that! In addition I am using a 25% DSMO gel 2x daily and it is a game changer. I just rub it on my knee, wait 30 minutes and go do your recommended exercises. I would like to suggest that you look into DSMO and how it helps with damaged tendons and ligaments. I use Jacobs Lab brand that I got off of reading A Midwestern Doctors substack. Between you two doctors and your excellent advice I am finally turning a corner and getting my life back. I can't thank you two enough! Dr Luks excersises+DSMO=Winning!
Dr. Luks, I REALLY appreciate your words of wisdom! 72 year old multi sport athlete here, last 140.6 was in 2012. Racing on/off since 1968. Stretched my training week to 9 days at age 65. One too many bike crashes resulted in right hip arthritis and then hip resurfacing in 2023 (also have manageable back/hand arthritis). Largely recovered and was on track to do a slow IM 70.3 Dallas last March. Caught that aggressive Type A flu in December and still have not recovered. I feel tired all the time and not sleeping well. Currently doing a sleep study, hopeful but not confident on a positive outcome. Tracking sleep with a Garmin Forerunner - RSV is stable in the low 30s, deep sleep only averaging a couple of hours a night. Resting heart rate stable in the low 50's. I often have really severe restless legs syndrome at bedtime, can last 3-4 hours. Recently ramped up magnesium and potassium supplements in the evening, seems to help a bit. My PCP says my blood work is pretty boring, very normal. Online forums and normal medical advice all seems to be the same but doesn't seem to help. Is this tiredness/sleeplessness normal at 72, something old geezers just have to push through, or is there a process that older athletes should use to evaluate their energy levels?
DAVID…. post viral syndromes are very real!! Most will hammer our autonomic nervous system. This happened to me after a bout of COVID and it too a very very long time to get it behind me. I wrote two posts on post-viral syndromes… you should search my substack for them.
One key… do not push intensity at all. You will likely pay a very heavy price for it. Eventually… with lots of saunas, hot baths, walks, rucks, and easy hikes I got it behind me… but it was a long painful climb out of that one.
OK, you did ask. Canadian, Male. 152lb, 5'10", Irish, Scottish, French. I've been extremely active since the late 80's (68 now). My sports are cycling (road, cyclocross, gravel....before it exploded and mountain bike) both for training, just fun and racing fairly seriously. Winter I fat bike, XC ski and snow shoe. I strength train year round but more in winter. I've overcome many health issues and radically changed my intensity and volume after getting AFIB (paroxysmal with flutter) in 2021. I learned I flipped into AFIB if my heart rate exceeded 120ish bpm. The only symptom I had was shortage of breath. When I was really fit my resting HR was 28bpm. I had a catheter ablation in 2021. I haven't had AFIB since. I use a Fourth Frontier X2 heart/ECG monitor anytime I exercise. After a very long time trying to figure out my "changed" heart I am consistently exercising again. The issue I have figured out is my sympathetic system. It is incredibly sensitive. If I am driving to an appointment I will get strong feeling of anxiety, fight/flight being triggered but I am calmly breathing through my nose, I have made sure I have pretty of time. Exercising, quick efforts cause my HR to jump far more rapidly than pre-ablation and lead to a messy ECG tracing....PVCs, PACs both of which can continue after I stop the efforts. Keeping my HR above ~135will result in the same tracing. It was ~145 before. Just walking up a flight of stairs at home or the night time bathroom visit can make my HR rapidly start pounding. I use that word because of the feeling not that it is really rapidly beating, maybe 90-95. Just typing this note out has me feeling an increase in the sympathetic response. Checking HRV just doesn't work as any little twinge etc makes the readings erratic. Resting HR lying down then standing has given me the most consistent idea of being rested but it sure isn't like it was pre-ablation. Currently 40/51 would appear to be seen when I know I'm rested but this doesn't consistently indicate how I'll feel exercising. I gave up racing years ago, the ego beating has pretty much been accepted, my intensity is down massively, endurance down to a 1/3 of pre-ablation. Road/gravel cycling because they can be more steady than technical mountain biking with short intense efforts needed to avoid walking. VO2 max training/efforts I can do but the PHD exercise physiologist who reads my FF tracing says those efforts result in really ugly data and as no one has a clue whether this will result in AFIB again etc I default to not going there. At no time do I experience lightheadedness, chest pain or any of the other flags.
Although the cardiologists did a great job of the ablation any cardiologist I've spoken to are well and truly ignorant about exercise beyond being able to walk up stairs and carry groceries into your home. Then there's the...where I fit on the bell curve for age...method of assessing people my age.
Long ramble to ask what can I do to damp down my hyperactive sympathetic system?
Sounds like what you're describing is post-ablation autonomic remodeling. Ablation damages autonomic nerve fibers in the atrial wall. They regrow, but are disorganized and less effective. Your sympathetic system is now hypersensitive... the signal is too loud for the stimulus.
You haven't had AFib since 2021. The ablation worked. Now you need to recalibrate. Things that may work.
Breathwork. Slow breathing at about 6 breaths per minute with a gentle emphasis on the exhale. Five minutes before every ride, during easy spinning, and before bed. This directly stimulates vagal tone and brakes sympathetic output. Also like boxed breathing… 4 sec in, 4 sec hold, 4 sec out, 4 sec hold.
Slow the transitions. 15 to 20-minute conversational warm-up a ride/run. Cool down slowly. The PVCs and PACs with quick efforts are catecholamine surges.r Give it a longer on-ramp.
Discuss these next few with your cardiologist.
Magnesium glycinate or taurate, 400 to 600mg daily. Stabilizes cardiac cell membranes, reduces ectopic firing. A meta-analysis showed it roughly halved ventricular and supraventricular arrhythmias compared with placebo. Many endurance athletes are deficient.
Taurine, 2 to 3 grams daily. Evidence is anecdotal and mechanistic, not large trials. Partial GABA agonist with membrane-stabilizing properties. Some clinicians report reduced ectopy. Worth considering if your doc agrees, given the safety profile, but the data is preliminary.
Eat fish 2 to 3 times a week. Do NOT take high-dose fish oil supplements. Meta-analyses show omega-3 supplements above 1g/day increase AFib risk (HR 1.49). Given your AFib history and a pre-ablation resting HR of 28, high-dose fish oil is the wrong move. Dietary fish appears protective... supplements at typical doses do not.
Keep strength training. Low-to-moderate-intensity resistance training may help maintain autonomic balance and baroreceptor function.
Consider discussing a low-dose beta blocker with your cardiologist for harder effort days. 12.5 to 25mg of metoprolol an hour before a ride could blunt the sympathetic surge. Not daily... a tool for days you want to push.
Stop chasing HRV. Your post-ablation heart doesn't follow those algorithms. Your lying-to-standing test is better.
You've already made the hardest adjustments. A 68-year-old who cycles, skis, snowshoes, and strength trains year-round is so far to the right on any health curve that we're just polishing.
You may want to read The Haywire Heart by Dr. Jon Mandrola.
Imagine any cardiologist in the world giving a basically well but worried patient a counseling package this balanced, evidence-based, detailed, and reassuring, even including nutritional interventions. I can't. Bravo.
My mother once said we expect instant cures for illness, but our body doesn’t work that way. I am in my mid seventies, and have been doing weights on and off since my thirties, as well as running, now walking. About two months ago, started doing deadlifts, which I have never done before. Slowly but surely, I can feel the difference they are making in posture, balance and confidence. My point is, getting older doesn’t mean giving up, but it does require an understanding that while exercise might not have a noticeable impact in one week, slowly things will improve, and then in time, you will realize you can and have improved. Sorry, this isn’t what you were asking for, but I think older people, friends, are too quick to dismiss exercise, and I have no idea how to motivate them.
1) Recovering from grief and a life that looks a lot different from what I had expected and dreamed, and from what it used to be.
My husband died suddenly six months ago; no warning. I found him on the floor at home.
This, after marked improvement in a chronic , life-threatening health condition that he'd had for five years and that had significantly affected our family habits and routines, and our mental health (the condition was not a mental health condition).
The physical effects of grief are real: decreased energy, and fluctuating myofascial pain and stiffness.
We used to be a very active family. Bicycle rides (15-20 miles) several times a week, walks after dinner, hiked on vacation. His health condition changed all of that.
I had started back, somewhat, over the last couple of years. But feel slammed back to the floor by grief. Reduced to walks around the neighborhood when I used to fly free on my bike. Going out on my bike is not only physically difficult at times, but also carries an emotional weight as I remember the joy we used to have as a family when we rode and the rides my husband and I did together.
2) doing the "simple" or "minimal" activity anyway. Like walking the neighborhood for 20 minutes. Trusting that this will be "enough" until my mind, soul, and body recover. It feels very frustrating and discouraging to be limited in what I can do. Will I ever truly recover? Or is this yet another loss?
I’m so sorry. That’s one of the hardest things I think. A friend lost her husband this year, married for 50 years. It’s starting to cross my mind at times. No one can feel that loss though we try
Amy, as you know grief is moment to moment, day by day, week to week, month by month.....and unpredictable. You're rebuilding. It'll take awhile to see the results- but know that you're creating a new you. Every moment, every day, every week,every month...... I've been in your shoes. It's hard, really, hard. Keep at it. Allow yourself to grieve and when each of those moments pass, pick up and move. My best to you and your family
Wow, I just skimmed the comments. You have a lot of work to get to!
I love your posts and love that they seem so age appropriate. (I'm from the: "only young once but immature forever" school). Retired cardiologist but I am taking a vacation from retirement for a year of clinic work in New Zealand. Now that I'm back at work I'm having trouble finding time to work out as regularly as I should. I also feel that I am suffering from some sarcopenia. I was seriously overweight (250 lbs) and after a year or two on tirzepatide (Mounjaro) am stable at 180 lbs +/-. It doesn't seem to matter how much time I spend weight training, my hips and shoulders just won't stop aching. I've taken to doing twenty minutes of exercise after getting out of bed (pushups, lateral leg raises, squats, RDLs) and that seems to have helped. And the problems keep coming. Now I'm dealing with medial epicondylitis. But the fatigue is the strangest symptom of getting older. I never used to need to get in bed at 8:00 pm, and I can fall asleep at the drop of a hat anytime I get home.
Audrey Hepburn said getting old wasn't for sissies and she wasn't kidding
I'm 66, female,newly retired- and loving the time I have to get active and improve my balance, strength, endurance....Dr Luk you're an inspiration.
My biggest challenge is obesity. I' m working with a physician on the nutrition part, medical labs and such. Not particularly working, but I am getting stronger by hitting 600-900 active minutes a week. The information and perspective you provided is helpful to me on a daily basis.
Thank you, Anne! Especially as we age, this can be a huge issue and source of frustration. That’s an amazing level of activity— congratulations. This is where GLP-1 medications can be considered…. I wrote a whole series on them if you want to look at them.
First, I want to thank you for the Enough/Better/Optimal series. I did a 12 inch box jump 5 times at the gym this afternoon after building up to it for months!
Also, I truly appreciate how generous you are with the free subscriber content. I particularly like your graphics. My favorite is “Comfort is slowly stealing your freedom”. Have you read Michael Easter’s The Comfort Crisis?
My main struggle with the 10-year goal of maximum physical fitness is the reasonable fear of economic/political/climate collapse. While that’s certainly possible, and even likely, I truly want to spend each day enjoying the beautiful life I lead now. I’m almost 65, 33 years sober, happily married, with a healthy weight and good labs. I wish I could say I’m in excellent health; my asthma, migraines, and kidney disease are chronic but well-managed.
For future posts, I’d appreciate some writing for those of us who habitually avoid high intensity. I did a single Norwegian 4 minute stairs/squats interval this week and made my heart pound like it almost never does. When I ruck, I often go with lighter weight than optimal. When I walk, I usually dawdle. I've built a nice weekly schedule thanks to your recommendations with plenty of recovery built in. Thank you again for truly helping me every day with your words.
Hello, I'm 38 and trying to get to a solid 2 hours of movement every day. Right now I'm recovering from some PTT tendinopathy and seemingly related shin splints caused by overuse/load leading up to what was supposed to be a Paris marathon in April. Went to the doctor at NYU and they didn't find anything, MRI and XRays both came back negative/unremarkable so that's good. But otherwise they were pretty much useless. lol
I've been slowly building since taking a week off in April. Just trying to take my "medicine" and be humble, not add much volume each week. I'm back to walking about 8-12k steps a day. I was thinking I might do run walk in a couple weeks.
I had a somewhat similar overuse injury the prior spring my inner knee was really sore, not the day of, but the day after I went on a regular long run and did some strides. Think the knee was just on edge and that tipped into the injury territory.
As someone who doesn't struggle with motivation and discipline my issues seem to be much more related to missing cues that I should've caught related to overuse. Niggles, etc. With that when I do get into overuse territory I'd rather not fully stop movement but finding the right movement that is beneficial and not just slowing the recovery process is not straightforward. I guess this is where living in the middle of the Catskills is a bit annoying and regularly meeting a PT is not very convenient.
I guess another issue I have is because I come from cycling my CV system seems very capable of handling the running, but that's also where I get into trouble because all the tendons (as you have been talking about!) are slower to adapt and knowing how much is too much or too little ends up being pretty tough. Almost like nothing hurts/is sore until I have a tendon flare.
Anyway thanks for all the resources you've shared on here. 🙏 Trying to consume and understand them as much as I can. I really appreciate the no nonsense practical advice. Simple rules/guides are much easier to follow than someone's "recovery" plan that feels like a differential equation problem 😂
This is ultimately a problem that cannot be solved: Coming to peace with the aging of my body. I am now 76. I am not looking for obvious advice: I train aerobically, and have lifted heavy for 13 or so years now: deadlift and back squat. Every year I must adjust my goals downward. (Actually, my problem is the same as Sarah's-so perhaps it would be a useful topic to address!)
For me, as a longtime ultra-distance runner who also does strength/mobility at age 57, I’m overall satisfied and feel youthful. The issue I struggle with (but am making peace with) is the comparison trap of comparing myself to how I performed in my forties. I hope I’ll still traverse mountains and my body won’t hurt as I do it in my late sixties. If I can, I want to celebrate that and be in the moment rather than bemoan how much slower I move and how much more rest I need. I’m grateful I still feel motivation for that. Related: it’s an ongoing struggle in my long marriage that my spouse is uninterested in working out, and he’s aging more rapidly. So a limitation for me may be feeling lonely and frustrated that I can’t share my outdoor adventures with my partner because he lacks the physical capability and motivation. I learned long ago that I can’t change him, and our marriage has lasted in part with the attitude “you do you,” and he is fine with how he is and generously supports my sport. But he’s not very healthy, which pains me. I’m sure I’m not the only reader in your health-conscious audience who faces this issue with their partner!
I expect there are a large number of us to live in a similar situation. My wife is older than me (by 6yrs) and has a laundry list of health issues that have drastically ramped up in the past 5 years. And due to those issues, there really isn't much she can do to improve her situation.
I am committed to doing what I can but came to the 'crashing plane' realization - you have to save yourself before you can help anyone else...
My gosh, that is a big issue for me but one I hadn't even recognized until reading your comment!
I am going to be 78 in September. I am fairly fit as I have maintained a workout of some description since my late 30s. Jane Fonda, running , step workouts, cardio kickboxing. I didn't get serious about weights until my 60s when hiking became my passion and I struggled to do steep climbs. But now, late 70s, I am struggling with arthritic knees, my right hand, my elbows are getting grumpy. My fear is how to keep my fitness level. There isn't much information for women my age. I was so happy to find you because you make so much sense and aren't selling something. However you seem to be geared mostly to men which is fine. Lots of your advice works for both genders. I have modified my workouts. Resting more. Eating more protein. Taking supplements. Knees are biggest problem. My biggest fear is to lose my mobility.
Thanks, Dawn. I don't purposefully pass on advice meant just for men. A lot of the junk science shared about exercise in women is simply wrong. The overwhelming majority of solid clinical evidence is that women need the same types of training that men do, although I do add more jumping and impact loading for women, and most clients over 50 for bone density issues.
That's where confusion arises as there are people who insist training for women isn't the same as for men. I became overwhelmed with it all and just started listening to you and one other male on Substack. Common sense advice. Went back to what I already knew worked for me and got me this far.
My biggest obstacles? Two things:
1) Even after following your plan (4-5 days a week of Zone 2 run-walking plus one day of HIIT, plus 2 days/week of strength) for about 3 months, I’m still plateaued and not making any progress. I’m 61 so my expectations are low, but still, it’s discouraging.
2). The above-described program is extremely time consuming and it does interfere with other important things that I want to spend my time on.
I’ve been doing this (or something similar) for several years. I’ve been doing light running since I was 48. I do it because my health is important to me. Still, it’s becoming discouraging, the double whammy of not seeing progress while also sacrificing time that I could really use for things that are important to me.
Despite my current (today’s) state of mind, I want to add that I’m very grateful to still be healthy and active, and I do appreciate that all the work I’ve done for years is making that possible. Also, I’m still following your writing because I’ve found it very valuable - a rare source of in-depth but sound advice for my age group - and I appreciate it very much.
I want to learn what I need to continue running, ideally injury-free, and my motivator is always understanding how things work, so I appreciate your thorough explanations. I'm a septuagenarian who has been running several marathons annually for decades. Until recently, I've been of the belief that the best training for running is running. In recent years, though, I've started getting minor injuries and the most effective part of my PT has been the strengthening exercises that target problem areas, so I'm finally appreciating the importance of strength training. (Also I trusted my PT's advice more after reading "Painful Tendons want Load" and better understood how that works.) What I most appreciate about your writing is learning how the body works, and the value of doing (inevitably boring) strength work.
My first job was working as an orderly on a ward that looked after those whom nursing homes could not properly look after.
I saw, first hand, the effects of poor diet and a comfortable retirement.
I tore my meniscus and MCL 5 months ago. Recovery has been so painful and slow. I also have arthritis and about 70% cartilage left. I am a 66 yo female and not in good shape before the injury. I have done 3 rounds of PT, PRP injection, steroid injection. None of those helped much and I would argue made me worse. I discovered your stack and have been doing your isometric exercises and am finally getting back to me. Thank you for that! In addition I am using a 25% DSMO gel 2x daily and it is a game changer. I just rub it on my knee, wait 30 minutes and go do your recommended exercises. I would like to suggest that you look into DSMO and how it helps with damaged tendons and ligaments. I use Jacobs Lab brand that I got off of reading A Midwestern Doctors substack. Between you two doctors and your excellent advice I am finally turning a corner and getting my life back. I can't thank you two enough! Dr Luks excersises+DSMO=Winning!
Dr. Luks, I REALLY appreciate your words of wisdom! 72 year old multi sport athlete here, last 140.6 was in 2012. Racing on/off since 1968. Stretched my training week to 9 days at age 65. One too many bike crashes resulted in right hip arthritis and then hip resurfacing in 2023 (also have manageable back/hand arthritis). Largely recovered and was on track to do a slow IM 70.3 Dallas last March. Caught that aggressive Type A flu in December and still have not recovered. I feel tired all the time and not sleeping well. Currently doing a sleep study, hopeful but not confident on a positive outcome. Tracking sleep with a Garmin Forerunner - RSV is stable in the low 30s, deep sleep only averaging a couple of hours a night. Resting heart rate stable in the low 50's. I often have really severe restless legs syndrome at bedtime, can last 3-4 hours. Recently ramped up magnesium and potassium supplements in the evening, seems to help a bit. My PCP says my blood work is pretty boring, very normal. Online forums and normal medical advice all seems to be the same but doesn't seem to help. Is this tiredness/sleeplessness normal at 72, something old geezers just have to push through, or is there a process that older athletes should use to evaluate their energy levels?
Papa
Never ever ever stop moving
DAVID…. post viral syndromes are very real!! Most will hammer our autonomic nervous system. This happened to me after a bout of COVID and it too a very very long time to get it behind me. I wrote two posts on post-viral syndromes… you should search my substack for them.
One key… do not push intensity at all. You will likely pay a very heavy price for it. Eventually… with lots of saunas, hot baths, walks, rucks, and easy hikes I got it behind me… but it was a long painful climb out of that one.
OK, you did ask. Canadian, Male. 152lb, 5'10", Irish, Scottish, French. I've been extremely active since the late 80's (68 now). My sports are cycling (road, cyclocross, gravel....before it exploded and mountain bike) both for training, just fun and racing fairly seriously. Winter I fat bike, XC ski and snow shoe. I strength train year round but more in winter. I've overcome many health issues and radically changed my intensity and volume after getting AFIB (paroxysmal with flutter) in 2021. I learned I flipped into AFIB if my heart rate exceeded 120ish bpm. The only symptom I had was shortage of breath. When I was really fit my resting HR was 28bpm. I had a catheter ablation in 2021. I haven't had AFIB since. I use a Fourth Frontier X2 heart/ECG monitor anytime I exercise. After a very long time trying to figure out my "changed" heart I am consistently exercising again. The issue I have figured out is my sympathetic system. It is incredibly sensitive. If I am driving to an appointment I will get strong feeling of anxiety, fight/flight being triggered but I am calmly breathing through my nose, I have made sure I have pretty of time. Exercising, quick efforts cause my HR to jump far more rapidly than pre-ablation and lead to a messy ECG tracing....PVCs, PACs both of which can continue after I stop the efforts. Keeping my HR above ~135will result in the same tracing. It was ~145 before. Just walking up a flight of stairs at home or the night time bathroom visit can make my HR rapidly start pounding. I use that word because of the feeling not that it is really rapidly beating, maybe 90-95. Just typing this note out has me feeling an increase in the sympathetic response. Checking HRV just doesn't work as any little twinge etc makes the readings erratic. Resting HR lying down then standing has given me the most consistent idea of being rested but it sure isn't like it was pre-ablation. Currently 40/51 would appear to be seen when I know I'm rested but this doesn't consistently indicate how I'll feel exercising. I gave up racing years ago, the ego beating has pretty much been accepted, my intensity is down massively, endurance down to a 1/3 of pre-ablation. Road/gravel cycling because they can be more steady than technical mountain biking with short intense efforts needed to avoid walking. VO2 max training/efforts I can do but the PHD exercise physiologist who reads my FF tracing says those efforts result in really ugly data and as no one has a clue whether this will result in AFIB again etc I default to not going there. At no time do I experience lightheadedness, chest pain or any of the other flags.
Although the cardiologists did a great job of the ablation any cardiologist I've spoken to are well and truly ignorant about exercise beyond being able to walk up stairs and carry groceries into your home. Then there's the...where I fit on the bell curve for age...method of assessing people my age.
Long ramble to ask what can I do to damp down my hyperactive sympathetic system?
cheers ian
Sounds like what you're describing is post-ablation autonomic remodeling. Ablation damages autonomic nerve fibers in the atrial wall. They regrow, but are disorganized and less effective. Your sympathetic system is now hypersensitive... the signal is too loud for the stimulus.
You haven't had AFib since 2021. The ablation worked. Now you need to recalibrate. Things that may work.
Breathwork. Slow breathing at about 6 breaths per minute with a gentle emphasis on the exhale. Five minutes before every ride, during easy spinning, and before bed. This directly stimulates vagal tone and brakes sympathetic output. Also like boxed breathing… 4 sec in, 4 sec hold, 4 sec out, 4 sec hold.
Slow the transitions. 15 to 20-minute conversational warm-up a ride/run. Cool down slowly. The PVCs and PACs with quick efforts are catecholamine surges.r Give it a longer on-ramp.
Discuss these next few with your cardiologist.
Magnesium glycinate or taurate, 400 to 600mg daily. Stabilizes cardiac cell membranes, reduces ectopic firing. A meta-analysis showed it roughly halved ventricular and supraventricular arrhythmias compared with placebo. Many endurance athletes are deficient.
Taurine, 2 to 3 grams daily. Evidence is anecdotal and mechanistic, not large trials. Partial GABA agonist with membrane-stabilizing properties. Some clinicians report reduced ectopy. Worth considering if your doc agrees, given the safety profile, but the data is preliminary.
Eat fish 2 to 3 times a week. Do NOT take high-dose fish oil supplements. Meta-analyses show omega-3 supplements above 1g/day increase AFib risk (HR 1.49). Given your AFib history and a pre-ablation resting HR of 28, high-dose fish oil is the wrong move. Dietary fish appears protective... supplements at typical doses do not.
Keep strength training. Low-to-moderate-intensity resistance training may help maintain autonomic balance and baroreceptor function.
Consider discussing a low-dose beta blocker with your cardiologist for harder effort days. 12.5 to 25mg of metoprolol an hour before a ride could blunt the sympathetic surge. Not daily... a tool for days you want to push.
Stop chasing HRV. Your post-ablation heart doesn't follow those algorithms. Your lying-to-standing test is better.
You've already made the hardest adjustments. A 68-year-old who cycles, skis, snowshoes, and strength trains year-round is so far to the right on any health curve that we're just polishing.
You may want to read The Haywire Heart by Dr. Jon Mandrola.
Ask
Opus 4.6
Imagine any cardiologist in the world giving a basically well but worried patient a counseling package this balanced, evidence-based, detailed, and reassuring, even including nutritional interventions. I can't. Bravo.
My mother once said we expect instant cures for illness, but our body doesn’t work that way. I am in my mid seventies, and have been doing weights on and off since my thirties, as well as running, now walking. About two months ago, started doing deadlifts, which I have never done before. Slowly but surely, I can feel the difference they are making in posture, balance and confidence. My point is, getting older doesn’t mean giving up, but it does require an understanding that while exercise might not have a noticeable impact in one week, slowly things will improve, and then in time, you will realize you can and have improved. Sorry, this isn’t what you were asking for, but I think older people, friends, are too quick to dismiss exercise, and I have no idea how to motivate them.
Thank you… so important for people to read these types of messages. You’ll never know who you might inspire to start.
1) Recovering from grief and a life that looks a lot different from what I had expected and dreamed, and from what it used to be.
My husband died suddenly six months ago; no warning. I found him on the floor at home.
This, after marked improvement in a chronic , life-threatening health condition that he'd had for five years and that had significantly affected our family habits and routines, and our mental health (the condition was not a mental health condition).
The physical effects of grief are real: decreased energy, and fluctuating myofascial pain and stiffness.
We used to be a very active family. Bicycle rides (15-20 miles) several times a week, walks after dinner, hiked on vacation. His health condition changed all of that.
I had started back, somewhat, over the last couple of years. But feel slammed back to the floor by grief. Reduced to walks around the neighborhood when I used to fly free on my bike. Going out on my bike is not only physically difficult at times, but also carries an emotional weight as I remember the joy we used to have as a family when we rode and the rides my husband and I did together.
2) doing the "simple" or "minimal" activity anyway. Like walking the neighborhood for 20 minutes. Trusting that this will be "enough" until my mind, soul, and body recover. It feels very frustrating and discouraging to be limited in what I can do. Will I ever truly recover? Or is this yet another loss?
I agree that depression can be the greatest obstacle to getting up and moving.
No matter how many people tell you that exercise will help with the depression.
It helps, sometimes, to remind myself how I will feel after I am done walking.
And this isn't depression. It's grief. Although the two can look similar.
both can be true
I’m so sorry. That’s one of the hardest things I think. A friend lost her husband this year, married for 50 years. It’s starting to cross my mind at times. No one can feel that loss though we try
Amy, as you know grief is moment to moment, day by day, week to week, month by month.....and unpredictable. You're rebuilding. It'll take awhile to see the results- but know that you're creating a new you. Every moment, every day, every week,every month...... I've been in your shoes. It's hard, really, hard. Keep at it. Allow yourself to grieve and when each of those moments pass, pick up and move. My best to you and your family
Finding meaning and purpose in life.
Wow, I just skimmed the comments. You have a lot of work to get to!
I love your posts and love that they seem so age appropriate. (I'm from the: "only young once but immature forever" school). Retired cardiologist but I am taking a vacation from retirement for a year of clinic work in New Zealand. Now that I'm back at work I'm having trouble finding time to work out as regularly as I should. I also feel that I am suffering from some sarcopenia. I was seriously overweight (250 lbs) and after a year or two on tirzepatide (Mounjaro) am stable at 180 lbs +/-. It doesn't seem to matter how much time I spend weight training, my hips and shoulders just won't stop aching. I've taken to doing twenty minutes of exercise after getting out of bed (pushups, lateral leg raises, squats, RDLs) and that seems to have helped. And the problems keep coming. Now I'm dealing with medial epicondylitis. But the fatigue is the strangest symptom of getting older. I never used to need to get in bed at 8:00 pm, and I can fall asleep at the drop of a hat anytime I get home.
Audrey Hepburn said getting old wasn't for sissies and she wasn't kidding
Keep up the great work
Your biggest fan
I'm 66, female,newly retired- and loving the time I have to get active and improve my balance, strength, endurance....Dr Luk you're an inspiration.
My biggest challenge is obesity. I' m working with a physician on the nutrition part, medical labs and such. Not particularly working, but I am getting stronger by hitting 600-900 active minutes a week. The information and perspective you provided is helpful to me on a daily basis.
Thank you, Anne! Especially as we age, this can be a huge issue and source of frustration. That’s an amazing level of activity— congratulations. This is where GLP-1 medications can be considered…. I wrote a whole series on them if you want to look at them.
Hi, Dr. Howard! Thanks for asking…
First, I want to thank you for the Enough/Better/Optimal series. I did a 12 inch box jump 5 times at the gym this afternoon after building up to it for months!
Also, I truly appreciate how generous you are with the free subscriber content. I particularly like your graphics. My favorite is “Comfort is slowly stealing your freedom”. Have you read Michael Easter’s The Comfort Crisis?
My main struggle with the 10-year goal of maximum physical fitness is the reasonable fear of economic/political/climate collapse. While that’s certainly possible, and even likely, I truly want to spend each day enjoying the beautiful life I lead now. I’m almost 65, 33 years sober, happily married, with a healthy weight and good labs. I wish I could say I’m in excellent health; my asthma, migraines, and kidney disease are chronic but well-managed.
For future posts, I’d appreciate some writing for those of us who habitually avoid high intensity. I did a single Norwegian 4 minute stairs/squats interval this week and made my heart pound like it almost never does. When I ruck, I often go with lighter weight than optimal. When I walk, I usually dawdle. I've built a nice weekly schedule thanks to your recommendations with plenty of recovery built in. Thank you again for truly helping me every day with your words.
Hello, I'm 38 and trying to get to a solid 2 hours of movement every day. Right now I'm recovering from some PTT tendinopathy and seemingly related shin splints caused by overuse/load leading up to what was supposed to be a Paris marathon in April. Went to the doctor at NYU and they didn't find anything, MRI and XRays both came back negative/unremarkable so that's good. But otherwise they were pretty much useless. lol
I've been slowly building since taking a week off in April. Just trying to take my "medicine" and be humble, not add much volume each week. I'm back to walking about 8-12k steps a day. I was thinking I might do run walk in a couple weeks.
I had a somewhat similar overuse injury the prior spring my inner knee was really sore, not the day of, but the day after I went on a regular long run and did some strides. Think the knee was just on edge and that tipped into the injury territory.
As someone who doesn't struggle with motivation and discipline my issues seem to be much more related to missing cues that I should've caught related to overuse. Niggles, etc. With that when I do get into overuse territory I'd rather not fully stop movement but finding the right movement that is beneficial and not just slowing the recovery process is not straightforward. I guess this is where living in the middle of the Catskills is a bit annoying and regularly meeting a PT is not very convenient.
I guess another issue I have is because I come from cycling my CV system seems very capable of handling the running, but that's also where I get into trouble because all the tendons (as you have been talking about!) are slower to adapt and knowing how much is too much or too little ends up being pretty tough. Almost like nothing hurts/is sore until I have a tendon flare.
Anyway thanks for all the resources you've shared on here. 🙏 Trying to consume and understand them as much as I can. I really appreciate the no nonsense practical advice. Simple rules/guides are much easier to follow than someone's "recovery" plan that feels like a differential equation problem 😂
This is ultimately a problem that cannot be solved: Coming to peace with the aging of my body. I am now 76. I am not looking for obvious advice: I train aerobically, and have lifted heavy for 13 or so years now: deadlift and back squat. Every year I must adjust my goals downward. (Actually, my problem is the same as Sarah's-so perhaps it would be a useful topic to address!)