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A history of heart disease isn't something you try to outrun.

Dr. Terry Kavanagh, medical director of the cardiac secondary prevention and rehabilitation program at Toronto Rehabilitation Institute, has prescribed running for many of his recovering heart patients over the past 32 years. He estimates he has sent 60 to 70 bypass and transplant patients on to the ranks of marathon running.

But sometimes, a year removed from a life-threatening situation, a person thinks he or she has cheated death and can take on the world. Wrong.

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"The adrenaline starts to flow and certain personalities strive too much," says Kavanagh, who is also an associate professor in the University of Toronto department of medicine. "Don't get carried away with the event. A marathon shouldn't be a race for them. It's an achievement."

Kavanagh says the death of former heart surgery patient Warren Plumb of Sharon, Ont., at the Walt Disney World Marathon on the weekend was an extremely rare occurrence.

Plumb, 56, collapsed about two kilometres into the race. Despite on-the-scene attention from a half-dozen paramedics and a state trooper, who were also competing in the race, he died of cardiac arrest. From the scar running down his chest and scars on both legs, the paramedics noticed at once he'd had heart surgery, and he carried nitroglycerin tablets while running.

"The incidence of death in marathon is very low, almost infinitesimal," Kavanagh said. An 18-year study of two major marathons in the United States, the Marine Corps and Twin Cities marathons, found a death rate of 1 in 50,000, or four fatal heart attacks in almost two decades of running.

"We have a cardiac rehab program, which started in 1968. It started with walking and progressed to jogging, where it's appropriate for bypass surgery patients and transplants," Kavanagh said.

The impetus for the a program of physical activity came from the fact that in those days "people would be looked at as cardiac cripples. Companies would pass over them for promotions. They wouldn't be allowed to do anything. The aim was to point out that a patient who made a good recovery was capable of doing something and of taking up a normal life again," he said.

In 1973, six graduates of Kavanagh's medically prescribed and supervised running program entered the Boston Marathon and all of them finished it. The doctor himself is a 3-hour, 25-minute marathoner. He has run with some of the ex-patients, but he has never had heart surgery himself.

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The last time Kavanagh ran with his group of graduates was 1985 and they were a herd of 15, including Englishman Brian Price, the first heart transplant patient to finish a marathon race. He did so only 15 months after surgery.

"When patients finish the program and become enthusiastic about running, we check them out and give them a training program and schedule. We test them and test them and advise them to hydrate properly [drink enough fluids during a run. We've also said 'no' where we don't think they should take on distance runs.

"We have 1,600 new patients referred every year, and four or five in the past few year aspired to marathon.

"I'd be concerned about someone who decided on his own after transplant surgery or a bypass to run without first having a full assessment. We point out all the things they should know. We give them a copy of a book I've written on how to prepare for a marathon. It'd be foolhardy to think you are just as good as new and run the way you used to run. It takes a good year's preparation.

"They have to be carefully instructed that everything is not the same as it was before. Don't get carried away with competing with anyone other than yourself. Watch the pace. Pick a marathon that's not too hilly, not in hot weather and enjoy it."

Above all, the cardiac patient who takes up running has to listen to his or her body. The highly publicized death in the early 1980s of U.S. distance runner Jim Fixx was sometimes pointed to as a warning that too much exercise is a dangerous thing. But Kavanagh says the autopsy and subsequent reports showed Fixx had ignored several warning signs. His father had heart disease and died young and Fixx himself had been a smoker.

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"There's a saying that sudden cardiac death is unexpected -- but it's seldom unheralded."

Kavanagh said of the seven patients who ran the Boston Marathon in 1973, six are still alive. One died in his sleep in 1975 of a congenital abnormality. "And of the six who are alive, the oldest is 82, and most of us meet every week for a walk-jog. I can beat some of them."

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