Alterations in coagulatory and fibrinolytic systems following an ultra-marathon

D-dimer - a multifaceted molecule

D-dimer, a universally unique marker for fibrin degradation, is generated through the enzymatic interplay of thrombin, factor XIIIa, and plasmin. The emergence of D-dimer-containing fibrin molecules occurs in both intravascular and extravascular spaces during pivotal physiological processes like haemostasis, thrombosis, and tissue repair. Given the inherently physiological nature of fibrin formation and fibrinolysis, basal levels of D-dimer fragments are present in plasma. Beyond its role as a marker of routine physiological processes, aberrations in D-dimer levels are indicative of a spectrum of conditions, both non-pathological and pathological. The clinical utility of D-dimer has been firmly established, particularly in scenarios like venous thromboembolism (VTE), pulmonary embolism (PE), deep vein thrombosis (DVT), and disseminated intravascular coagulation (DIC). Additionally, recent applications have extended to assess the prognosis of COVID-19. While D-dimer is commonly associated with thrombotic conditions, its elevation is not confined to these conditions alone. Elevated D-dimer levels are observed across various diseases, where its significance extends beyond diagnostic indicators to prognostic implications.

Ultra-Endurance Participation and Acute Kidney Injury: A Narrative Review

Increasingly popular, ultra-endurance participation exposes athletes to extremely high levels of functional and structural damage. Ultra-endurance athletes commonly develop acute kidney injury (AKI) and other pathologies harmful to kidney health. There is strong evidence that non-steroidal anti-inflammatory drugs, common amongst ultra-athletes, is linked to increased risk and severity of AKI and potentially ischaemic renal injury, i.e., acute tubular necrosis. Ultra-endurance participation also increases the risk of exertional rhabdomyolysis, exercise-associated hyponatremia, and gastrointestinal symptoms, interlinked pathologies all with potential to increase the risk of AKI. Hydration and fuelling both also play a role with the development of multiple pathologies and ultimately AKI, highlighting the need for individualised nutritional and hydration plans to promote athlete health. Faster athletes, supplementing nitrates, and being female also increase the risk of developing AKI in this setting. Serum creatinine criteria do not provide the best indicator for AKI for ultra-athletes therefore further investigations are needed to assess the practicality and accuracy of new renal biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL). The potential of recurring episodes of AKI provide need for further research to assess the longitudinal renal health impact of ultra-participation to provide appropriate advice to athletes, coaches, medical staff, and event organisers.

Recommendations on the Appropriate Level of Medical Support at Ultramarathons

Participation in ultramarathons continues to grow, especially among older individuals and among younger runners who may have less running and wilderness experience than many past participants. While ultramarathons tend to have relatively few serious medical issues, adverse medical incidents do occur. These factors make it increasingly important that appropriate safety precautions and medical support are defined and implemented at these events to enhance the safety of participants, spectators, and volunteers. This document establishes the minimum recommended level of medical support that should be available at ultramarathons based on current knowledge and the experience of the authors. It offers a balance that is intended to avoid excessive stress on the local medical system while also precluding undue burden on events to provide medical support beyond that which is practical. We propose a three-level classification system to define the extent of medical services, personnel, systems, supplies, and equipment in place and recommend the level of medical support based on event size, distance/duration, remoteness, and environmental conditions that may be encountered during the event. This document also outlines the recommended education and training of medical providers and discusses other medical and logistical considerations related to the provision of medical support at ultramarathons. We suggest that ultramarathon organizers review and adopt these recommendations to enhance safety and reduce the risk of adverse events to participants.

Exercise Is Medicine? The Cardiorespiratory Implications of Ultra-marathon

Regular physical activity decreases the risk of cardiovascular disease, type II diabetes, obesity, certain cancers, and all-cause mortality. Nevertheless, there is mounting evidence that extreme exercise behaviors may be detrimental to human health. This review collates several decades of literature on the physiology and pathophysiology of ultra-marathon running, with emphasis on the cardiorespiratory implications. Herein, we discuss the prevalence and clinical significance of postrace decreases in lung function and diffusing capacity, respiratory muscle fatigue, pulmonary edema, biomarkers of cardiac injury, left/right ventricular dysfunction, and chronic myocardial remodeling. The aim of this article is to inform risk stratification for ultra-marathon and to edify best practice for personnel overseeing the events (i.e., race directors and medics).

Management of venous thromboembolism in athletes

Venous thromboembolism (VTE) is a common condition with high associated morbidity and mortality. Athletes have unique VTE risk factors compared with the general population, and may have a higher than anticipated risk of thrombosis. Anticoagulant treatment poses additional challenges in athletes, as these individuals usually wish to return to sporting activities without delay. In addition, those athletes who engage in contact sports may have bleeding complications with extended anticoagulation. In this paper, we discuss VTE risk factors in athletes, the impact of exertion on haemostasis, measures which could be adopted to mitigate VTE risks in these highly active individuals and options to deal with bleeding risks from anticoagulation during injury-prone sporting activities.

Compression socks and the effects on coagulation and fibrinolytic activation during marathon running

PURPOSE

Compression socks are frequently used in the treatment and prevention of lower-limb pathologies; however, when combined with endurance-based exercise, the impact of compression socks on haemostatic activation remains unclear.

OBJECTIVES

To investigate the effect of wearing compression socks on coagulation and fibrinolysis following a marathon.

METHODS

Sixty-seven participants [43 males (mean ± SD: age: 46.7 ± 10.3 year) and 24 females (age: 40.0 ± 11.0 year)] were allocated into a compression (SOCK, n = 34) or control (CONTROL, n = 33) group. Venous blood samples were obtained 24 h prior to and immediately POST-marathon, and were analyzed for thrombin-anti-thrombin complex (TAT), tissue factor (TF), tissue factor pathway inhibitor (TFPI), and D-Dimer.

RESULTS

Compression significantly attenuated the post-exercise increase in D-Dimer compared to the control group [median (range) SOCK: + 9.02 (- 0.34 to 60.7) ng/mL, CONTROL: + 25.48 (0.95-73.24) ng/mL]. TF increased following the marathon run [median (range), SOCK: + 1.19 (- 7.47 to 9.11) pg/mL, CONTROL: + 3.47 (- 5.01 to 38.56) pg/mL] in all runners. No significant post-exercise changes were observed for TAT and TFPI.

CONCLUSIONS

While activation of coagulation and fibrinolysis was apparent in all runners POST-marathon, wearing compression socks was shown to reduce fibrinolytic activity, as demonstrated by lower D-Dimer concentrations. Compression may reduce exercise-associated haemostatic activation when completing prolonged exercise.

Physiology and Pathophysiology in Ultra-Marathon Running

In this overview, we summarize the findings of the literature with regards to physiology and pathophysiology of ultra-marathon running. The number of ultra-marathon races and the number of official finishers considerably increased in the last decades especially due to the increased number of female and age-group runners. A typical ultra-marathoner is male, married, well-educated, and ~45 years old. Female ultra-marathoners account for ~20% of the total number of finishers. Ultra-marathoners are older and have a larger weekly training volume, but run more slowly during training compared to marathoners. Previous experience (e.g., number of finishes in ultra-marathon races and personal best marathon time) is the most important predictor variable for a successful ultra-marathon performance followed by specific anthropometric (e.g., low body mass index, BMI, and low body fat) and training (e.g., high volume and running speed during training) characteristics. Women are slower than men, but the sex difference in performance decreased in recent years to ~10–20% depending upon the length of the ultra-marathon. The fastest ultra-marathon race times are generally achieved at the age of 35–45 years or older for both women and men, and the age of peak performance increases with increasing race distance or duration. An ultra-marathon leads to an energy deficit resulting in a reduction of both body fat and skeletal muscle mass. An ultra-marathon in combination with other risk factors, such as extreme weather conditions (either heat or cold) or the country where the race is held, can lead to exercise-associated hyponatremia. An ultra-marathon can also lead to changes in biomarkers indicating a pathological process in specific organs or organ systems such as skeletal muscles, heart, liver, kidney, immune and endocrine system. These changes are usually temporary, depending on intensity and duration of the performance, and usually normalize after the race. In longer ultra-marathons, ~50–60% of the participants experience musculoskeletal problems. The most common injuries in ultra-marathoners involve the lower limb, such as the ankle and the knee. An ultra-marathon can lead to an increase in creatine-kinase to values of 100,000–200,000 U/l depending upon the fitness level of the athlete and the length of the race. Furthermore, an ultra-marathon can lead to changes in the heart as shown by changes in cardiac biomarkers, electro- and echocardiography. Ultra-marathoners often suffer from digestive problems and gastrointestinal bleeding after an ultra-marathon is not uncommon. Liver enzymes can also considerably increase during an ultra-marathon. An ultra-marathon often leads to a temporary reduction in renal function. Ultra-marathoners often suffer from upper respiratory infections after an ultra-marathon. Considering the increased number of participants in ultra-marathons, the findings of the present review would have practical applications for a large number of sports scientists and sports medicine practitioners working in this field.

Adherence to Follow-Up Recommendations by Triathlon Competitors Receiving Event Medical Care

Introduction. We sought to investigate triathlete adherence to recommendations for follow-up for participants who received event medical care. Methods. Participants of the 2011 Ironman Syracuse 70.3 (Syracuse, NY) who sought evaluation and care at the designated finish line medical tent were contacted by telephone approximately 3 months after the initial encounter to measure adherence with the recommendation to seek follow-up care after event. Results. Out of 750 race participants, 35 (4.6%) athletes received event medical care. Of these 35, twenty-eight (28/35; 80%) consented to participate in the study and 17 (61%) were available on telephone follow-up. Of these 17 athletes, 11 (11/17; 65%) of participants reported that they had not followed up with a medical professional since the race. Only 5 (5/17; 29%) confirmed that they had seen a medical provider in some fashion since the race; of these, only 2 (2/17; 12%) sought formal medical follow-up resulting from the recommendation whereas the remaining athletes merely saw their medical providers coincidentally or as part of routine care. Conclusion. Only 2 (2/17; 12%) of athletes who received event medical care obtained postrace follow-up within a one-month time period following the race. Event medical care providers must be aware of potential nonadherence to follow-up recommendations.

Determinants of recovery from a 161-km ultramarathon

The primary study objective was to identify determinants of short-term recovery from a 161-km ultramarathon. Participants completed 400 m runs at maximum speed before the race and on days 3 and 5 post-race, provided a post-race blood sample for plasma creatine kinase (CK) concentration, and provided lower body muscle pain and soreness ratings (soreness, 10-point scale) and overall muscular fatigue scores (fatigue, 100-point scale) pre-race and for 7 days post-race. Among 72 race finishers, soreness and fatigue had statistically returned to pre-race levels by 5 days post-race; and 400 m times at days 3 and 5 remained 26% (P = 0.001) and 12% (P = 0.01) slower compared with pre-race, respectively. CK best modelled soreness, fatigue and per cent change in post-race 400 m time. Runners with the highest CKs had 1.5 points higher (P < 0.001) soreness and 11.2 points higher (P = 0.006) fatigue than runners with the lowest CKs. For the model of 400 m time, a significant interaction of time with CK (P < 0.001) indicates that higher CKs were linked with a slower rate of return to pre-race 400 m time. Since post-race CK was the main modifiable determinant of recovery following the ultramarathon, appropriate training appears to be the optimal approach to enhance ultramarathon recovery.

Biomarker Changes after Strenuous Exercise Can Mimic Pulmonary Embolism and Cardiac Injury—A Metaanalysis of 45 Studies

BACKGROUND

Biomarkers are well established for diagnosis of myocardial infarction [cardiac troponins, high-sensitivity cardiac troponins (hs-cTn)], exclusion of acute and chronic heart failure [B-type natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP)] and venous thromboembolism (d-dimers). Several studies have demonstrated acute increases in cardiac biomarkers and altered cardiac function after strenuous sports that can pretend a cardiovascular emergency and interfere with state-of-the-art clinical assessment.

METHODS

We performed a systematic review and metaanalysis of biomarker and cardiovascular imaging changes after endurance exercise. We searched for observational studies published in the English language from 1997 to 2014 that assessed these biomarkers or cardiac function and morphology directly after endurance exercise. Of 1787 identified abstracts, 45 studies were included.

RESULTS

Across all studies cardiac troponin T (cTnT) exceeded the cutoff value (0.01 ng/mL) in 51% (95% CI, 37%–64%) of participants. The measured pooled changes from baseline for high-sensitivity cTnT (hs-cTnT) were +26 ng/L (95% CI, 5.2–46.0), for cTnI +40 ng/L (95% CI, 21.4; 58.0), for BNP +10 ng/L (95% CI, 4.3; 16.6), for NT-proBNP +67 ng/L (95% CI, 49.9; 84.7), and for d-dimer +262 ng/mL (95% CI, 165.9; 358.7). Right ventricular end diastolic diameter increased and right ventricular ejection fraction as well as the ratio of the early to late transmitral flow velocities decreased after exercise, while no significant changes were observed in left ventricular ejection fraction.

CONCLUSIONS

Current cardiovascular biomarkers (cTnT, hs-cTnT, BNP, NT-proBNP, and d-dimer) that are used in clinical diagnosis of pulmonary embolism, acute coronary syndrome, and heart failure are prone to alterations due to strenuous exercise. Hence, it is necessary to take previous physical exercise into account when a cardiac emergency is suspected.

Effect of cycling in the heat for 164 km on procoagulant and fibrinolytic parameters

PURPOSE

We assessed the impact of completing the Hotter'n Hell Hundred (HHH), an annual 164 km road cycling event performed in a hot environment, on hemostatic balance in men.

METHODS

Sixteen men who completed the ride in <6 h were included in this study. Plasma samples were collected on that morning of the ride (PRE) and immediately on the completion of the ride (IP). Primary hemostasis was assessed by platelet count and von Willebrand factor antigen (vWF:Ag). Coagulation was assessed by measuring prothrombin fragment 1 + 2 (PTF 1 + 2) and thrombin-antithrombin complex (TAT), whereas fibrinolysis was assessed by plasminogen activator inhibitor antigen (PAI-1 Ag), tissue plasminogen activator (tPA Ag), and D-Dimer analyses.

RESULTS

Compared to PRE, increases (p < 0.001) were observed at IP for platelets (39 %), vWF:Ag (65 %), PTF 1 + 2 (47 %), TAT (81 %), tPA Ag (231 %), PAI-1 Ag (148 %), and D-Dimer (54 %). PRE PAI-1 Ag concentrations were directly related to BMI and waist circumference (p < 0.05). D-Dimer concentrations at IP correlated positively with age (p < 0.05).

CONCLUSIONS

Completing the HHH activated the coagulation and fibrinolytic systems in balance. Age was positively correlated with IP D-Dimer concentrations. Additionally, participants displaying a larger BMI and waist circumference exhibited a positive correlation with PRE PAI-1 Ag concentrations.