Dev (name changed) is a 45-year-old hard driving Silicon Valley executive who was referred to me for a consult after experiencing a heart attack. I reviewed his chart before seeing him in the exam room and expected to see the typical overweight, insulin resistant, inactive patient but was surprised to see that Dev looked remarkably fit. He actually had a company physical with labs a year before that showed normal lipids, normal blood pressure, and normal blood glucose. He was an exercise fanatic who ran 5 days a week and attended spin classes on weekends. He had no family history of heart disease and ate a healthy diet. The only thing that stood out on his lab report was an elevated hsCRP, a marker for inflammation. What was going on? Dev’s case was not unique. Although the majority of patients I see have identifiable, mostly reversible risk factors for heart disease like diabetes, obesity, and abnormal cholesterol, I’m seeing a growing number of occult heart disease in remarkably fit and healthy appearing patients. They may have most of the usual items checked off their healthy lifestyle list, like nutrition and exercise, but they continue to push one key factor aside….STRESS! Even after Dev’s heart attack, his hsCRP levels remained elevated and he had a hard time accepting the fact that his intense workout regimen layered upon a high stress lifestyle may have been the culprit. There is growing evidence that endurance athletes like marathon runners may have a higher risk of developing heart disease as discussed here. Most of my patients are not training at this level, but many are leading highly stressful lives followed by intense workouts with very little rest periods in between.