Doctors said that many things -- including alcohol and cocaine abuse, anorexia, as well as cancer treatments could contribute to an early heart attack.
Certain types of chemotherapy can weaken the heart muscle temporarily or permanently. Radiation can also affect the heart muscle and the pericardium, the sac around the heart.
"It also accelerates the aging process," said Hayes. "We as cardiologists learn of new side effects of these drugs when they reach middle age. We see [heart disease] at 51 that we would see at 66."
One chemotherapy drug -- adriamycin, which is in a class of anthracylines -- can be especially toxic to the heart, she said. "We have known about heart toxicity for decades and try to limit doses."
Lung cancer treatments can cause blockages or a sudden heart attack, which could be exacerbated if a patient ever smoked or has heart disease. They can also cause heart rhythm abnormalities.
Those who have been treated for Hodgkins disease as children, lung cancer and left-sided breast cancer can be particularly vulnerable to later cardiovascular disease.
"For women, it's a no-win," said Hayes. "They survived breast cancer 20 years ago and thought it was a miracle. Then they develop radiation-induced heart disease."
Women may also be more vulnerable to treatments, according to Hayes. "We don't have good data because a lot of times they don't separate it out by gender. They have smaller arteries to start with and a smaller body size. We don't fully understand the sex differences."
As for Kennedy's workout, during which the heart attack happened, doctors have long known that certain arrhythmias could be provoked by exercise.
Though Kennedy was also thin, doctors said it was hard to know if that was part of a healthy lifestyle or a sign of an underlying health condition. "The esophagus is within the range [of the lung] and some people who have radiation for lung cancer end up with an esophagus [problem] and it's harder to eat," said Hayes.
Heavy alcohol use can also contribute to a weakening of the heart muscle, and drugs like cocaine can cause an acute heart attack from elevated blood pressure.
"We are curing more people and giving them newer drugs to let them live well with cancer," said Hayes. "But there are lots of costs."
One of Hayes' patients found that the drug that worked so well controlling his spindle cell cancer for a decade landed him with heart failure. "We had to stop, and it was a gut-wrenching decision -- to die or the cancer won't be controlled," she said.
Hayes is currently treating a woman in her 60s whose deadly inflammatory breast cancer was cured by radical treatments in her 30s. But by 55, she had developed severe heart valve disease because of heavy radiation doses. Now, at 60, she is on a ventilator for heart and lung problems.
"I think she will come through it," said Hayes. "If asked, she would never say she regretted having the 20 years to see her children grow up and to have grandchildren. But this reality pushes us cardiologists to be aware and deal with the side effects. And it pushed our cancer colleagues to come up with treatments that are more specific to the disease and less toxic."