While preparing this article, I received a highly pertinent letter from a 62-year-old hiker hoping to thru-hike the Appalachian Trail. He had all his equipment and was training. While hiking up a moderate hill this June he had severe chest pains and had to rest. Twelve years earlier he had chest pains that required a cardiac balloon angioplasty, which dilated one of two clogged coronary arteries. He has been doing some cardiac rehabilitation and has had some anginal pain during exercise but is reluctant to have an angiogram (X-ray and dye visualization of the coronary arteries), which his cardiologist suggests. This patient has probably not had an infarct but is clearly at risk for one. I advised him that if he wants to continue to train for the trail he must first get complete medical clearance to reduce his risks. I suspect that the angiogram will show arterial narrowing and that until this is treated by dilatation he may precipitate a serious episode during strenuous exertion. After he is treated, preparation for the trail will be an uphill struggle, requiring considerable dedication.

Standard medical practice after myocardial infarction aims to restore the patient to normal activity by carefully graded exercise that is closely monitored by symptom assessment and EKGs. There are other approaches for dealing with angina and arrhythmia patients. After rehabilitation has restored the patient to normal activity status, physical conditioning for the trail can begin with walking moderate distances without a pack and then with a pack. I suggest a program based upon Ray Jardine's recommendations (The Pacific Crest Trail Hiker's Handbook) as modified by my own experience. It includes hiking, aerobic training by running moderate distances, and weight training for legs and arms. Every hiker must design his or her own schedule.

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