Mortality among marathon runners in the United States, 2000-2009

Demographics, culture and participatory nature of multi-marathoning-An observational study highlighting issues with recommendations

OBJECTIVES

The defining achievement of a multi-marathoner is completing 100 marathons. This study aimed to comprehensively document the phenomenon of multi-marathoning, addressing its demographics, culture and participatory nature, filling a gap in peer-reviewed research on the topic. Additionally, it aimed to provide recommendations for multi-marathon governing bodies, event organisers, health professionals and participants to address identified issues.

METHODS

A global survey was distributed to participants and individuals interested in multi-marathoning. It was distributed with support from major national and international multi-marathon clubs through their social media channels, email groups and newsletters. The survey was conducted anonymously and online.

RESULTS

The survey garnered responses from 830 participants across 40 countries, with an average marathon completion count of 146.54 (SD 201.83) per respondent. Gender distribution showed 60.69% men, 39.3% women and 0.1% gender variant/non-conforming. Respondents' average ages were 51.6 (SD 9.96) years for men, 48.83 (SD 9.15) years for women and 35.00 (SD 8.76) years for gender variant/non-conforming. As participants age, social and travel motivations surpass competitiveness. A majority (57%) of respondents had at least one contravention to the pre-participation screening questionnaire PARQ-+ and 67% reported taking pain relief medication around events. Notably, 93% of respondents reported multi-marathoning as beneficial for their mental health.

DISCUSSION

Multi-marathoning accommodates older athletes, but a significant gender imbalance exists in participation levels. Long-term health implications warrant attention from governing bodies, event organisers, health professionals and participants alike. Multi-marathoners should seek medical advice before participation, utilise modern equipment for health monitoring and optimise training accordingly.

CONCLUSION

Recommendations include encouraging diversity at events, ensuring event directors have well-resourced health plans and promoting participants' proactive health management before and during their involvement in the sport. This study not only advances our understanding of multi-marathoning as a sport but also contributes to theoretical frameworks such as SDT and HBM.

Exertional Heat Stroke Survival at the Falmouth Road Race: 180 New Cases With Expanded Analysis

CONTEXT

A high number of exertional heat stroke (EHS) cases occur during the Falmouth Road Race.

OBJECTIVES

To extend previous analyses of EHS cases during the Falmouth Road Race by assessing or describing (1) EHS and heat exhaustion (HE) incidence rates, (2) EHS outcomes as they relate to survival, (3) the effect of the environment on these outcomes, and (4) how this influences medical provider planning and preparedness.

DESIGN

Descriptive epidemiologic study.

SETTING

Falmouth Road Race.

PATIENTS OR OTHER PARTICIPANTS

Patients with EHS or HE admitted to the medical tent.

MAIN OUTCOME MEASURE(S)

We obtained 8 years (2012 to 2019) of Falmouth Road Race anonymous EHS and HE medical records. Meteorologic data were collected and analyzed to evaluate the effect of environmental conditions on the heat illness incidence (exertional heat illness [EHI] = EHS + HE). The EHS treatment and outcomes (ie, cooling time, survival, and discharge outcome), number of HE patients, and wet bulb globe temperature (WBGT) for each race were analyzed.

RESULTS

A total of 180 EHS and 239 HE cases were identified. Overall incidence rates per 1000 participants were 2.07 for EHS and 2.76 for HE. The EHI incidence rate was 4.83 per 1000 participants. Of the 180 EHS cases, 100% survived, and 20% were transported to the emergency department. The WBGT was strongly correlated with the incidence of both EHS (r2 = 0.904, P = .026) and EHI (r2 = 0.912, P = .023).

CONCLUSIONS

This is the second-largest civilian database of EHS cases reported. When combined with the previous dataset of EHS survivors from this race, it amounts to 454 EHS cases resulting in 100% survival. The WBGT remained a strong predictor of EHS and EHI cases. These findings support 100% survival from EHS when patients over a wide range of ages and sexes are treated with cold-water immersion.

A comparison of two pre-race medical screening tools in 5771 running race entrants-SAFER XXVIII

OBJECTIVE

To determine if two pre-race screening tools (abbreviated tool of two open-ended pre-race medical screening questions [ABBR] vs. a full pre-race medical screening tool [FULL]) identify running race entrants at higher risk for medical encounters (MEs) on race day.

METHODS

5771 consenting race entrants completed both an ABBR and a FULL pre-race screening questionnaire for the 2018 Comrades Marathon (90 km). ABBR tool questions were (1) allergies, and (2) known medical conditions and/or prescription medication use. The FULL tool included multiple domains of questions for chronic diseases including cardiovascular disease (CVD), symptoms, risk factors, allergies and medication use. ABBR responses were manually coded and compared to the FULL tool. The prevalence (%: 95%CI), and the test for equality of prevalence of entrants identified by the ABBR vs. FULL tool is reported.

RESULTS

The ABBR identified fewer entrants with allergies (ABBR = 7.9%; FULL = 10.4%: p = 0.0001) and medical conditions/medication use (ABBR = 8.9%; FULL = 27.4%: p = 0.0001). The ABBR tool significantly under-reported entrants with history of cardiovascular disease (CVD), CVD risk factors, other chronic diseases and prescription medication vs. the FULL tool (p = 0.0001). The ABBR tool identified fewer entrants in the "high" (ABBR = 3.4%; FULL = 12.4%) and "very high" risk (ABBR = 0.5%; FULL = 3.4%) categories for race day MEs (p = 0.0001).

CONCLUSIONS

An abbreviated pre-race screening tool significantly under-estimates chronic medical conditions, allergies, and race entrants at higher risk for MEs on race day, compared with a full comprehensive screening tool. We recommend that a full pre-race medical screening tool be used to identify race entrants at risk for MEs.

Effect of diet on cardiovascular health-related circulating parameters in men and women athletes participating in a marathon race: A cross-sectional study

OBJECTIVES

The main objective of this study is to understand how diet affects performance and cardiovascular health in a group of women participating in a demanding aerobic race such as marathon, compared to men.

METHODS

Fifteen women participating in the Barcelona Marathon-2016 were recruited to participate in the study. A group of men (n = 15) that performed the same marathon race was selected. Anthropometric parameters and diet records were collected before the race. Circulating parameters were analyzed 24 h-pre-race, immediately after the race and 48 h-post-race. These included certain minerals, lipid profile, muscle damage, inflammatory and cardiovascular health markers.

RESULTS

Diets were very similar in the men and women, with inadequate amounts of carbohydrates and proteins for endurance events. Creatine kinase (CK; a muscle damage marker) and C-reactive protein (CRP; a marker of inflammation) remained elevated 48 h post-race in all participants, but was significant in women (641 vs. 143 U/L for CK and 5.8 vs. 0.7 mg/dL for CRP). Cardiac markers (high sensitivity troponin T (Hs-TnT), suppression of tumorigenicity and N-terminal pro B-type natriuretic peptide) increased post-race and returned to pre-race values after 48 h in men and women. In particular, Hs-TnT (marker of myocyte stress) increased from 2.2 to 62.5 ng/L post-race in women and from 3.1 to 52.9 ng/L in men. Finally, circulating lipid parameters were at borderline unhealthy levels in both sexes.

CONCLUSION

Structural and functional cardiac advantages that women display compared to men in aerobic efforts are not manifested when diet is not adequately designed.

Using Wet Bulb Globe Temperature and Physiological Equivalent Temperature as Predicative Models of Medical Stress in a Marathon: Analysis of 30 Years of Data From the Twin Cities Marathon

OBJECTIVES

: Assess the relationships between wet bulb globe temperature (WBGT) and physiologic equivalent temperature (PET) at the start of a northern latitude marathon and their associations with medical stress and transfers to the emergency room (ER) when the race environment is unexpectedly warm, and participants are not acclimatized.

DESIGN

: Retrospective review.

SETTING

: Twin Cities Marathon from 1990 to 2019.

PARTICIPANTS

: Runners competing in the Twin Cities Marathon.

INDEPENDENT VARIABLES

: Start WBGT (prospectively collected) and PET (retrospectively calculated).

MAIN OUTCOME MEASURES

: Marathon race starters and finishers and race day medical data (eg, medical stress, number of medical encounters, and number of ER visits).

RESULTS

: The mean WBGT was 7.4°C (range -1.7°C to 22.2°C), and the meant PET was 5.2°C (range -16.7°C to 25.9°C). PET was not determined to be a significant predictor of medical stress (P = 0.71); however, a significant quadratic association between WBGT and medical stress was found (P = 0.006). WBGT (P = 0.002), but not PET (P = 0.07), was a significant predictor of the number of ER visits.

CONCLUSIONS

Start WBGT was a better predictor of medical stress and ER visits than PET at the Twin Cities Marathon over a 30-year period. The start WBGT may be a better tool to predict race day environment medical safety.

The Athlete's Heart-Challenges and Controversies: JACC Focus Seminar 4/4

Regular exercise promotes structural, functional, and electrical remodeling of the heart, often referred to as the "athlete's heart," with intense endurance sports being associated with the greatest degree of cardiac remodeling. However, the extremes of exercise-induced cardiac remodeling are potentially associated with uncommon side effects. Atrial fibrillation is more common among endurance athletes and there is speculation that other arrhythmias may also be more prevalent. It is yet to be determined whether this arrhythmic susceptibility is a result of extreme exercise remodeling, genetic predisposition, or other factors. Gender may have the greatest influence on the cardiac response to exercise, but there has been far too little research directed at understanding differences in the sportsman's vs sportswoman's heart. Here in part 4 of a 4-part seminar series, the controversies and ambiguities regarding the athlete's heart, and in particular, its arrhythmic predisposition, genetic, and gender influences are reviewed in depth.

Prehospital interventions and neurological outcomes in marathon-related sudden cardiac arrest using a rapid mobile automated external defibrillator system in Japan: a prospective observational study

OBJECTIVE

To describe neurological outcomes after sudden cardiac arrests (SCAs) in road and long-distance races using a rapid mobile automated external defibrillator system (RMAEDS) intervention.

METHODS

A total of 42 SCAs from 3 214 701 runners in 334 road and long-distance races from 1 February 2007 to 29 February 2020 were examined. Demographics, SCA interventions, EMS-related data and SCA-related outcomes were measured. Primary endpoints were favourable neurological outcomes (Cerebral Performance Categories 1-2) at 1-month and 1-year post-SCA. Secondary endpoints were factors related to the field return of spontaneous circulation (ROSC) and resuscitation characteristics, including the initial ECG waveform classification and resuscitation sequence times according to the initial ECG rhythm.

RESULTS

The SCA incidence rate was 1.31 per 100 000 runners (age: median (IQR), 51 (36.5, 58.3) years). Field ROSC and full neurological recovery at 1-month post-SCA was achieved 90.4% and 92.9% of cases, respectively. In 22 cases in which bystander cardiopulmonary resuscitation was initiated within 1 min and defibrillation performed within 3 min, full neurological recovery was achieved at 1-month and 1-year post-SCA in 95.5.% and 95.5% of cases, respectively.

CONCLUSIONS

The RMAEDS successfully treated patients with SCA during road and long-distance races yielding a high survival rate and favourable neurological outcomes. These findings support rapid intervention and the proper placement of healthcare teams along the race course to initiate chest compressions within 1 min and perform defibrillation within 3 min.

The Impact of Marathons on the Recovery of Heart Rate and Blood Pressure in Non-Professional Male Marathoners’ (≥45 Years)

Background and Objectives: Physical activity has a positive impact on health, and the participation in exercise and sports, including marathons, has increased in popularity. This kind of sport requires extreme endurance, which can cause different health problems and even lead to death. Participants without sufficient preparation and, in particular, men 45 years of age and older belong to a high risk group. The aim of this study was to determine the impact of marathons and cofactors associated with marathons on the recovery of heart rate (HR) and blood pressure (BP) of non-professional ≥ 45 years old male marathoners. Materials andMethods: A total of 136 ≥ 45 year old, non-professional (amateur marathoner), male participants were recruited. Data collection involved a questionnaire, body composition measures, and BP and HR results before and after finishing the marathon. Descriptive data, t-test, Mann–Whitney or χ² test, and Pearson’s correlation were applied. Results: Participants (skiing n = 81, cycling n = 29, running n = 26; mean age 51.7 ± 7.1 years old) had previously attended a median of 35 (IQR 17.5–66) marathons and travelled 2111.5 (IQR 920–4565) km. Recovery of HR and BP after finishing and recovery time was insufficient and not associated with marathon preparation. Running was the most burdensome for HR, and cycling was most taxing for BP. Chronic diseases did not influence participation in the marathon. Conclusions: The preparation for the marathon was mainly sufficient, but recovery after the marathon was worrisome. Marathons are demanding for ≥45 year old males and may be too strenuous an activity that has deleterious effects on health.

Burden of Injury and Illness in the Road Race Medical Tent: A Narrative Review

OBJECTIVE

To summarize the literature relating to prehospital care at 5 km through marathon distance road races and present the epidemiology of common medical encounters, significant medical complications, and medical outcomes.

DATA SOURCES

We searched PubMed and Google Scholar for the published literature pertaining to road race medical tent encounters at 5 km through marathon distance road races from 2000 to 2018. We included English-language, original articles reporting on injury and illness incidence.

MAIN RESULTS

Standard medical encounter definitions have recently been formulated in response to the previous lack of uniform definitions. The incidence of medical complications at road races may be influenced by environmental conditions and race distance. Minor and moderate medical encounters, such as dermatologic injuries, musculoskeletal injuries, and exercise-associated collapse, are common. Serious and life-threatening medical complications, including exertional heat stroke, exercise-associated hyponatremia, and cardiac arrest, are less frequent. Fatalities are also rare, with rates of 0.3 to 5 per 100 000 participants reported at marathons. The ratio of hospital transports to medical encounters is low.

CONCLUSIONS

On-site medical services play a key role in the safety of both runners and the community. Future research and care initiatives in this field should focus on optimizing treatment protocols, promoting injury prevention efforts and reducing host community costs.

Increased Participation and Decreased Performance in Recreational Master Athletes in "Berlin Marathon" 1974-2019

The aspect of participation and performance trends in marathon running has been investigated mainly in marathons held in the United States of America (e.g., “New York City Marathon,” “Boston Marathon”), but not for the fastest course in the world, the “Berlin Marathon” held in Berlin, Germany. This study aimed to examine trends in participation and performance in the “Berlin Marathon” on all its previous 46 editions from 1974 to 2019, the largest dataset ever studied in this event with 696,225 finishers (after data cleaning). Athletes in all age groups increased their participation, except for male athletes aged 20–49 years and athletes of both sexes above 79 years of age. This overall increase in participation was more pronounced in women, but still, there are more men than women participating in “Berlin Marathon” nowadays. All age group athletes decreased their performance across years overall, whereas the top ten recreational athletes improved their performance over the years. Our findings improved the knowledge about the evolution of male and female marathoners across calendar years, especially for the fastest marathon race in the world, the “Berlin Marathon.”

The Underrepresentation of Females in Studies Assessing the Impact of High-Dose Exercise on Cardiovascular Outcomes: a Scoping Review

High-dose exercise-induced cardiac outcomes may vary between sexes. However, many studies investigating the cardiovascular effects of high-dose exercise have excluded or under-recruited females. This scoping review aimed to describe the recruitment of females in studies assessing the impact of high-dose exercise on cardiovascular outcomes and describe how this has changed over time. This scoping review followed the protocol outlined by Arksey and O’Malley and is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines. The OVID and EMBASE databases were searched for studies that assessed the effects of high-dose exercise on cardiovascular outcomes. Both professional and nonprofessional groups were included. The review found 2973 studies, and 250 met the inclusion criteria including cumulatively 17,548,843 subjects. Over half the studies (n = 127) excluded females entirely, and only 8 (3.2%) studies recruited all-female participants. The overall mean percentage of females recruited was 18.2%. The mean percentage was 14.5% in studies conducted before 2011 and 21.8% in studies conducted after 2011. Females are an underrepresented group in studies assessing the cardiovascular outcomes related to high-dose exercise. As cardiovascular outcomes vary between sexes, translating findings from a largely male-based evidence may not be appropriate. Future investigators should aim to establish and overcome barriers to female recruitment.

Fatal Events Related to Running Competitions in the Mountains

INTRODUCTION

The few epidemiologic studies published previously about different forms of mountain running (ie, fell running, sky running, and ultratrail running) have not reported on fatal events. This report aims to contribute to the literature on mountain running fatalities, recording and classifying fatal events related to mountain running competitions found in online literature searches over a 12-y period.

METHODS

From 2008 to 2019, searches on mountain sport, mountain races, and newspaper websites were periodically performed, looking for fatal events related to running competitions in the mountains. Data are presented as mean±SD or percentage, as appropriate.

RESULTS

Fifty-one fatal events, involving 45 men (88%) and 6 women (12%), aged 50±11 and 46±6 y, respectively, were recorded in the 2008 to 2019 period in Western Europe. These events occurred during races (n=35; 69%), during training (n=13; 25%), and after races (n=3; 6%); 43% were sudden cardiac death, 32% due to falls (blunt trauma), 16% due to hypothermia, 4% due to both blunt trauma and hypothermia, 4% due to lightning strike injuries, and 2% due to animal attack (injuries from deer).

CONCLUSIONS

Understanding all of the causes of fatal events is necessary to institute preventative efforts and to organize rescues. Preventative efforts should be implemented by race organizers and by athletes themselves, and rescue teams can be trained and equipped to address all of these possible events. The relatively high percentage of sudden cardiac deaths stresses the need for preparticipation cardiovascular screenings. Further longitudinal studies are necessary to better understand the real impact of fatal events on the mountain running population.

Prevalence of Myocardial Fibrosis in Intensive Endurance Training Athletes: A Systematic Review and Meta-Analysis

Objective: To review the published literature reporting on the incidence of myocardial fibrosis (MF) in high-intensity endurance athletes measured by late gadolinium enhancement (LGE) with cardiac magnetic resonance imaging (CMR). Methods: Five databases (PubMed, Cochrane Controlled Trials Register, EMBASE, Web of Science, and SPORTDiscus) were searched to obtain case cohort studies published before November 10, 2019. From 96 abstracts or reports extracted, 18 full-text articles were reviewed. The incidence of LGE was reported as outcome measures. Subgroup analysis was performed by age (under or above 50 years). Pooled estimates were obtained using a fixed-effects model. Results: After a full-text assessment, 12 studies involving 1,359 participants were included for analysis. Among them, 163/772 participants in the endurance athletes group showed LGE positive, compared with 19/587 participants in the comparison group. The results of the meta-analysis suggested that the prevalence of LGE was higher in the athletes group with long-term endurance exercise (OR 7.20;95%CI: 4.51-11.49). In addition, the same conclusion was drawn after the stratification of age. Conclusions: The available evidence demonstrates that high-intensity endurance athletes is associated with an increased incidence of LGE positive.

Differences in coronary vasodilatory capacity and atherosclerosis in endurance athletes using coronary CTA and computational fluid dynamics (CFD): Comparison with a sedentary lifestyle

BACKGROUND

The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling.

METHODS

100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFR_CT), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio.

RESULTS

The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFR_CT (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects.

CONCLUSION

Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFR_CT for evaluation of coronary artery disease in endurance athletes.

Runners' metabolomic changes following marathon

Introduction

Marathon, as a long-distance aerobic exercise, has become a fashionable or popular sport. However, little is known about the holistic metabolic changes occurring within the serum metabolome of athletes after the completion of a marathon.

Objectives

The goal of current study was to have an in-depth understanding of the impact of marathon on human metabolomics as well as the relationships among a variety of metabolites.

Methods

The 20 studied subjects were all adult males who participated in a marathon. The serum samples of these participants were collected before and after the marathon and the biochemical metabolites in the serum were identified by an untargeted two-dimensional gas chromatography time-of-flight mass spectrometry.

Results

All participants completed the marathon within 3 h. Compared to those before exercise, serum urea and creatine kinase, as well as cortisol, elevated significantly (p < 0.05), whereas testosterone decreased significantly (p < 0.01). Metabolomic analysis showed that, compared to those before the competition, metabolites pyruvic acid, glyceric acid, malic acid, cis-aconitic acid, galacturonic acid, methyl fumaric acid, maltotriose, and others increased significantly after the competition (p < 0.05), but glucosamine and O-succinyl-L-homoserine decreased significantly (p < 0.05). Amino acid indexes, such as alanine, L-tyrosine and phenylalanine, increased significantly after exercise compared with those before exercise (p < 0.05), whereas serine, valine and asparagine decreased significantly (p < 0.05). Lipid metabolism indexes, glycerol, glyceric acid, octanoic acid, and quinic acid increased significantly (p < 0.05). Theophylline, xanthine and other indicators of caffeine metabolism increased significantly (p < 0.05). Furthermore, marathon performance, fat percentage, VO₂max, and hemoglobin were correlated with the serum metabonomic indicators, so were serum testosterone and cortisol.

Conclusion

These results illustrate that the metabolism of glucose and lipid of the athletes was enhanced following the marathon match. In addition, the metabolism of glucosamine was decreased and the metabolism of caffeine was increased. Our data provide new insights for marathon performance and nutritional status.

Cardiovascular Disease and Triathlon-Related Deaths in the United Kingdom

INTRODUCTION

Triathlon is one of the fastest growing sports in the United Kingdom. However, in recent years several deaths have occurred. The intention of this study is to identify these cases and examine the role cardiovascular disease played in these deaths.

METHODS

An extensive online search was performed to identify triathlon-related deaths (TRDs) in the United Kingdom and UK citizens who died during or as a result of competing in triathlons abroad. British Triathlon provided the number of participants who took part in UK-based events. Coroners provided information on all those who died.

RESULTS

Between 2009 and 2015, 991,186 participants took part in British Triathlon-sanctioned events. Five TRDs in the United Kingdom were identified. The mortality rate was 0.5 per 100,000 participants. Deaths occurred during or after the swim (3), cycle (1), and run (1) events. During the same period, 5 TRDs were identified among UK citizens competing abroad. These deaths occurred during or after the swim (2), cycle (1), and run (2) events. Cardiovascular pathology was cited as a cause or contributing factor in half of the fatalities. Four deaths were referred to a specialist cardiac pathology service for autopsy.

CONCLUSIONS

Cardiovascular disease was found to be the most common cause of TRD. Further research is needed to determine the underlying cardiac pathology that triggers TRDs. With this information it may be possible to develop screening tools that can prevent similar fatalities from occurring in the future.

Long distance training associated to HIIT protocol does not induce changes in blood biochemical markers in adult marathoners

ABSTRACT Objective: to verify blood markers during a 12-week training protocol and after Sao Paulo Marathon. Methods: Blood samples of 9 male marathoners were collected before (C1) and after (C2) 12-week training protocol, before (C3) and after (C4) marathon. Muscle and liver damage markers (creatine kinase [CK-MM], aspartate aminotransferase [AST], alanine aminotransferase [ALT]), oxidative stress levels (thiobarbituric acid reactive substances [TBARS]) and serum iron concentration were measured. Results: changes were identified comparing moment C4 to other moments for CK-MM and iron. For AST, ALT, and TBARS no differences were identified. Conclusion: strenuous exercises might elicit changes on blood markers, needing follow up strategies to avoid impairments to athletes’ performance and health.

Profiling Collapsing Half Marathon Runners-Emerging Risk Factors: Results from Gothenburg Half Marathon

Among several serious medical conditions, arrhythmia and heat stroke are two important causes of death during endurance races. Clinically, collapsing might be the first sign of these serious conditions and may mimic the more common and benign exercise-associated collapse. Several risk factors have been reported in the literature. We aimed to conduct a qualitative study to find a perceived risk profile among runners who collapsed and who were transported by ambulances to the nearest hospital during Gothenburg’s half marathon (2010–2017). Collapsing runners seem to lack the ability to make a decision to withdraw from the contest despite being exhausted. They feel the pain, but are unable to put meaning to their feeling, to adjust their pacing, and to handle other influences. Consequently, they do not overcome the problem or assess the situation. These individual mental characteristics may indicate a unique profile for collapsing runners. Pre-race health control and educational initiatives aiming at mental preparedness and information before endurance races might be a necessary step to avoid life-threatening complications.

Medical encounters, cardiac arrests and deaths during a 109 km community-based mass-participation cycling event: a 3-year study in 102 251 race starters-SAFER IX

BACKGROUND

There are few data on medical encounters, including deaths during mass-participation cycling events.

OBJECTIVE

To determine the incidence and nature of medical encounters during a community-based mass-participation cycling event.

DESIGN

Cross-sectional study across three annual events.

SETTING

2012-2014 Cape Town Cycle Tour (109 km), South Africa.

PARTICIPANTS

102 251 race starters (male=80 354, female=21 897).

METHODS

Medical encounters (moderate, serious life-threatening, sudden cardiac arrest/death), using the 2019 international consensus definitions, were recorded on race day for 3 years as incidence rates (IR per 1000 starters; 95% CI). Overall illness-related (by organ system) or injury-related (by anatomical region) encounters, and severity were recorded.

RESULTS

We recorded 539 medical encounters (IR 5.3; 4.8 to 5.7). The IR was 3.2 for injuries (2.9 to 3.6), 2.1 for illnesses (1.0 to 2.4) and 0.5 for serious life-threatening medical encounters (0.4 to 0.7). In the 3-year study, we encountered three cardiac arrests and one death (2.9 and 1.0 per 100 000 starters, respectively). Injury IRs included upper limb (1.9; 1.6 to 2.1), lower limb (1.0; 0.8 to 1.0) and head/neck (0.8; 0.6 to 1.0). Illness IRs included fluid/electrolyte abnormalities (0.6; 0.5 to 0.8) and the cardiovascular system (0.5; 0.4 to 0.6).

CONCLUSION

In a 109 km community-based mass-participation cycling event, medical encounters (moderate to severe) occurred in about 1 in 200 cyclists. Injury-related (1/300 cyclists) encounters were higher than illness-related medical encounters (1 in about 500). Serious life-threatening medical encounters occurred in 1/2000 cyclists. These data allow race organisers to anticipate the medical services required and the approximate extent of demand.

Mortality during marathons: a narrative review of the literature

Background

Millions of community-dwelling individuals run marathons each year. There are infrequent deaths, which are often reported widely, and may create unnecessary alarm about the potential risks. Equally, sensible planning for such eventualities is important when staging an event.

Objective

The aim of the review was to determine the risk of death from running a marathon and the likely location of such deaths in order to inform the public of the likely risks and improve planning for such events.

Design

Narrative review.

Data sources

Primary: PubMed. Secondary: contact was made with the organisers and medical teams of specific marathons and online data sought where necessary.

Eligibility criteria for selecting studies

Studies had to report the number of participants and deaths during, or within 24 hours of completing the marathon. Results relevant to half marathons or ultramarathons or other endurance events, such as triathlons, were not included. Deaths due to terrorist activity were not included.

Results

The risk of death estimated by these studies was approximately 0.67 per 100 000 finishers, that is, 1 death per 149 968 participants. From those studies that reported deaths by sex, the rate of male deaths was 0.98/100 000 (1 per 102 503) vs 0.41/100 000 (1 per 243 879) in females. Deaths tended to occur in the last quarter of the race.

Summary/conclusion

The risk of death from participating in a marathon is small. Men are more at risk than women. Deaths tend to occur later in the race.

The Age-Related Performance Decline in Marathon Running: The Paradigm of the Berlin Marathon

The variation of marathon race time by age group has been used recently to model the decline of endurance with aging; however, paradigms of races (i.e., marathon running) examined so far have mostly been from the United States. Therefore, the aim of the present study was to examine the age of peak performance (APP) in a European race, the “Berlin Marathon”. Race times of 387,222 finishers (women, n = 93,022; men, n = 294,200) in this marathon race from 2008 to 2018 were examined. Men were faster by +1.10 km.h⁻¹ (10.74 ± 1.84 km.h⁻¹versus 9.64 ± 1.46 km.h⁻¹, p <0.001, η² = 0.065, medium effect size) and older by +2.1 years (43.1 ± 10.0 years versus 41.0 ± 9.8 years, p < 0.001, η² = 0.008, trivial effect size) than women. APP was 32 years in women and 34 years in men using 1-year age groups, and 30–34 years in women and 35–39 years in men using 5-year age groups. Women’s and men’s performance at 60–64 and 55–59 age groups, respectively, corresponded to ~90% of the running speed at APP. Based on these findings, it was concluded that although APP occurred earlier in women than men, the observed age-related differences indicated that the decline of endurance with aging might differ by sex.

Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting

Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered 'musculoskeletal' (eg, strains) and those due to 'illness' (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.

Coronary atherosclerosis in apparently healthy master athletes discovered during pre-PARTECIPATION screening. Role of coronary CT angiography (CCTA)

BACKGROUND

Pre-participation screening (PPS) of athletes aged over 35 years (master athletes, MA) is a major concern in Sports Cardiology. In this population, sports-related sudden cardiac death is rare but usually due to coronary atherosclerosis (CA). Coronary CT Angiography (CCTA) has changed the approach to diagnosis/management of CA, but its role in this context still needs to be assessed.

METHODS AND RESULTS

We retrospectively examined 167 MA who underwent CCTA in our hospital since 2006, analyzing symptoms, stress-test ECG, cardiovascular risk profiles (SCORE) and CCTA findings. Among the whole enrolled population, 153 (91.6%) MA underwent CCTA for equivocal/positive stress-test ECG with/without symptoms, 13 (7.8%) just for clinical symptoms, 1 (0.6%) for the family history. The CCTA showed the presence of CA in 69 MA (41.3%), congenital coronary anomalies (anomalous origin or deep myocardial bridge) in 8 (4.8%), both in 7 (4.2%). A negative CCTA was observed in 83 MA (49.7%). The risk-SCORE (age, hypertension, hypercholesterolemia, smoking) was a good indicator for the presence of moderate/severe CA on CCTA. However, mild/moderate CA was present in 17.8% of MA clinically stratified at a low risk-SCORE.

CONCLUSION

While coronary angiography is more indicated in athletes with positive stress-test ECG and high clinical risk, the CCTA may be useful in the evaluation of MA with an abnormal stress test ECG and/or clinical symptoms engaged in competitive sports with a high cardiovascular involvement. Age, gender, presence of symptoms and clinical risk-SCORE assessment may help sports physicians and cardiologists to decide whether to request a CCTA or not.

Leisure athletes at risk of medical complications: outcomes of pre-participation screening among 15,778 endurance runners - SAFER VII

OBJECTIVE

International guidelines for pre-participation screening of masters/leisure athletes to identify those that require medical assessment exist, but have not been implemented in mass-community based sports events. We determined the prevalence of runners who, according to these guidelines, would require a medical assessment before participating in a distance running event.

METHODS

Participants of the 2012 Two Oceans races (21.1 and 56 km) in South Africa (n = 15,778) completed an online pre-race medical screening questionnaire using European pre-participation screening guidelines. We determined the prevalence of runners that would require a pre-race medical assessment, based on risk factors, symptoms, and disease.

RESULTS

The pre-participation "self assessment of risk" screening identified 4,941 runners (31.3%; 95% CI 30.6-32.0) that would need to undergo a full pre-participation medical assessment prior to running, if the current pre-participation screening guidelines are applied. Although musculoskeletal complaints and prescription medication use were the main triggers for a medical assessment, 16.8% (n = 2657) runners should undergo medical evaluation for suspected cardiac disease based on the questionnaire results: 3.4% (n = 538) reporting existing CVD (very high risk) and 13.4% (n = 2119) reporting multiple CVD risk factors (high risk). Other possible risk factors were reported as follows: history of chronic diseases (respiratory = 13.1%, gastro-intestinal = 4.3%, nervous system = 3.8%, metabolic/endocrine = 3.5%, allergies = 13.9%); chronic prescription medication = 14.8%, used medication before or during races = 15.6%; past history of collapse during a race = 1.4%.

CONCLUSIONS

Current guidelines identified that > 30% runners would require a full medical assessment before race participation - mainly linked to runners reporting musculoskeletal conditions. We suggest a revision of guidelines and propose that pre-race screening should be considered to identify runners with a "very high," "high," and "intermediate risk" for medical complications during exercise. Pre-race screening and educational intervention could be implemented to reduce medical complications during exercise.

Citius, Altius, Fortius vs. Slow Sport: A New Era of Sustainable Sport

The objective of the article is to present the slow sport movement as a phenomenon developing in the postmodern era in opposition to the idea of citius, altius, fortius (Eng. faster, higher, stronger). The theoretical part of the article describes the health repercussions of slow movement and its implications for the sports industry and sports tourism. It also points to new challenges in sports management and sports tourism implemented in the slow style. The empirical part of the article aims at determining what influence the achievement of a self-set sports goal has on the degree of satisfaction with participation in a running event among runners. Could runners who did not set themselves any sports goal and ran for pleasure (according to the idea of slow sport) achieve the same degree of satisfaction as runners who set themselves an ambitious sports goal and achieved it (according to the idea of citius, altius, fortius)? The case study is the 6th Poznan Half Marathon, a cyclical, popular running event taking place in Poland. A total of 560 runners (n = 560) took part in the diagnostic survey conducted using the interview technique. The ANOVA Rang Kruskal-Wallis test and Dunn's test were used in the study. The results show that athletes who did not set a sporting goal (ran for pleasure, company, atmosphere, participation, etc.) experienced the same level of satisfaction as athletes who achieved their intended sporting goal. It turns out, therefore, that sport and physical activity done for pleasure in accordance with the slow sport idea can provide the same level of satisfaction as sport practiced in the spirit of citius, altius, fortius.

Personality Traits and Vitamin D3 Supplementation Affect Mood State 12 h Before 100 km Ultramarathon Run

Background: Participation in extreme endurance sports is becoming an increasingly popular activity, and thus more and more people are getting involved in it. Taking part in a 100 km run is associated with great physiological and psychological stress, which can affect one’s mood state. Thus, the goal of this study was to determine if personality, experience, and motives for participation are related to a runner’s mood and its changes as well as to investigate whether vitamin D3 supplementation influences mood 12 h before and 12 h after the run.

Method: The study group consisted of 20 experienced marathon and ultramarathon runners taking part in a 100 km track run. All participants were males aged between 31 and 50 (M = 40.75, SD = 7.15). The group was divided in two equal subgroups: the placebo group and the group supplemented with vitamin D3. Personality traits were assessed using the Polish version of Eysenck’s EPQ-R 106 and mood states were measured twice (12 h before and after the run) using the Polish version of the UMACL by Mathews, Chamberlain, and Jones. Motives for participation in ultramarathons were measured with the IPAO by Lipowski and Zaleski.

Results: Levels of vitamin D3 correlated very strongly with energetic arousal (EA) (r_s = 0.80; p < 0.05) and strongly hedonic tone (HT) (r_s = 0.74; p < 0.05) 12 h before the run. There were no significant correlations between levels of vitamin D3 and mood states after the run. Moreover, extraversion correlated moderately with tense arousal (TA) (r_s = -0.48; p < 0.05) and EA (r_s = 0.47; p < 0.05) while neuroticism correlated moderately with TA (r_s = 0.53; p < 0.05) and HT (r_s = -0.57; p < 0.05).

Conclusion: Both personality and vitamin D3 supplementation are related to runners’ pre-run mood. These effects are nullified when it comes to post-run mood states.

Mortality in long-distance running races in Sweden - 2007-2016

Background

During the last decade, an increasing popularity of marathons has been seen. Although running has been shown to have considerable positive health effects, the risk of sudden death, most often due to sudden cardiac arrests, is also a risk runners expose themselves to. Whilst there are some studies on the mortality amongst long-distance runners, much of the evidence is dated. Given the increased popularity in running during the 21^st century as well as the improvements in medical care at marathons, more knowledge is required on the mortality risk.

Materials and method

Publicly available racing and news databases were used to identify the number of entrants and finishers in half to full marathons in Sweden between 2007 and 2016 and the number of deaths that occurred in conjunction with the races.

Results

A total of 1,156,271 runners entered a long distance (21-42km) running race in Sweden between 2007 and 2016, and 834,412 runners finished the races (72.2%). A large majority of the finishers (677,050 (81%)) competed in distances under a full marathon. Two deaths occurred during the time period, meaning that the death rate was 0.24 (95% confidence interval 0.04–0.79) per 100,000 finishers.

Conclusions

This study can show that death rates in long distance running races between 2007 and 2016 in Sweden are very low, compared to previous studies. When added to the existing literature, the combined picture suggests a general downward trend in the risk of death during marathons since the 1980s.

Poor knee function after ACL reconstruction is associated with attenuated landing force and knee flexion moment during running

PURPOSE

Poor knee function after anterior cruciate ligament reconstruction (ACLR) may increase the risk of future knee symptoms and knee osteoarthritis via abnormal knee joint loading patterns, particularly during high-impact activity. This study aimed to assess the relationship between poor self-reported or clinically measured knee function and knee moments/vertical ground reaction force (vGRF) in individuals following ACLR.

METHODS

61 participants (mean 16.5 ± 3 months following ACLR, 23 women) completed a patient-reported knee function questionnaire and three hop tests (% of uninvolved limb). Participants were divided into satisfactory and poor knee function groups (poor < 85% patient-reported knee function and/or < 85% hop test symmetry). The knee biomechanics of both groups were assessed with three-dimensional motion analysis during the stance phase of overland running at self-selected speeds, and the association between knee function and knee moments was assessed using analysis of covariance with running speed as a covariate.

RESULTS

Participants with poor knee function (n = 30) ran with significantly smaller peak knee flexion moments (moderate effect size 0.7, p = 0.03) and significantly smaller peak vGRFs (large effect size 1.0, p = 0.002) compared to those with satisfactory knee function (n = 31). No significant differences were observed for knee adduction and knee external rotation moments or knee kinematics.

CONCLUSION

Individuals following ACLR with poor self-reported knee function and/or hop test performance demonstrate knee moments during running that may be associated with lower knee joint contact forces. These findings provide greater understanding of the relationship between knee biomechanics during running and clinical assessments of knee function.

LEVEL OF EVIDENCE

III. Cross-sectional study.

Velocity distribution of women's 30-km cross-country skiing during Olympic Games from 2002-2014

BACKGROUND

Within several investigated endurance sport disciplines the distribution of load of the best competitors has a manner of evenly or slightly rising velocity values. Unfortunately many other competitors have usually diminishing values or when they are very poor they have evenly values. The aim of this study was to investigate distribution of velocity within 30-km cross-country female skiers.

METHODS

Cross-country skiing runs were investigated of Olympic Games 2002-2014 (Salt Lake City, Turin, Vancouver, Sochi). At every race two 15 km or three 10 km loops of the same vertical profile were taken into account. The competitors were divided onto: A) winners; B) medalists; C) competitors who obtained places 4 to 10 at the finish line (medium runners); and D) competitors who obtained places 11 to 30 at the finish line (poor runners). Velocity data presented on the web pages of several institutions were utilized.

RESULTS

The competitors had their velocity distributed in a manner with usually diminishing values. While comparing velocity of sequential loops with the mean velocity the difference for the poor runners reached the value of almost 6%, which was too high. There was significant (usually negative) correlation coefficient between values of velocity deviation for the first and second loops and the mean value of velocity for the entire distance for the better runners and mixed, i.e. positive and negative values for the poorer runners.

CONCLUSIONS

It was postulated investigations of velocity distribution should be introduced in coaching in order to inform competitors about their running. This advises is especially important for the poorer runners. Up to now cross-country skiers run for themselves. It should be discussed whether the tactics used by road and track runners, i.e. running with pace makers, can be introduced in cross country skiing. Also the use of a drone during training can be used in order to maintain proper pace.

Delays in Emergency Care and Mortality during Major U.S. Marathons

BACKGROUND

Large marathons frequently involve widespread road closures and infrastructure disruptions, which may create delays in emergency care for nonparticipants with acute medical conditions who live in proximity to marathon routes.

METHODS

We analyzed Medicare data on hospitalizations for acute myocardial infarction or cardiac arrest among Medicare beneficiaries (≥65 years of age) in 11 U.S. cities that were hosting major marathons during the period from 2002 through 2012 and compared 30-day mortality among the beneficiaries who were hospitalized on the date of a marathon, those who were hospitalized on the same day of the week as the day of the marathon in the 5 weeks before or the 5 weeks after the marathon, and those who were hospitalized on the same day as the marathon but in surrounding ZIP Code areas unaffected by the marathon. We also analyzed data from a national registry of ambulance transports and investigated whether ambulance transports occurring before noon in marathon-affected areas (when road closures are likely) had longer scene-to-hospital transport times than on nonmarathon dates. We also compared transport times on marathon dates with those on nonmarathon dates in these same areas during evenings (when roads were reopened) and in areas unaffected by the marathon.

RESULTS

The daily frequency of hospitalizations was similar on marathon and nonmarathon dates (mean number of hospitalizations per city, 10.6 and 10.5, respectively; P=0.71); the characteristics of the beneficiaries hospitalized on marathon and nonmarathon dates were also similar. Unadjusted 30-day mortality in marathon-affected areas on marathon dates was 28.2% (323 deaths in 1145 hospitalizations) as compared with 24.9% (2757 deaths in 11,074 hospitalizations) on nonmarathon dates (absolute risk difference, 3.3 percentage points; 95% confidence interval, 0.7 to 6.0; P=0.01; relative risk difference, 13.3%). This pattern persisted after adjustment for covariates and in an analysis that included beneficiaries who had five or more chronic medical conditions (a group that is unlikely to be hospitalized because of marathon participation). No significant differences were found with respect to where patients were hospitalized or the treatments they received in the hospital. Ambulance scene-to-hospital transport times for pickups before noon were 4.4 minutes longer on marathon dates than on nonmarathon dates (relative difference, 32.1%; P=0.005). No delays were found in evenings or in marathon-unaffected areas.

CONCLUSIONS

Medicare beneficiaries who were admitted to marathon-affected hospitals with acute myocardial infarction or cardiac arrest on marathon dates had longer ambulance transport times before noon (4.4 minutes longer) and higher 30-day mortality than beneficiaries who were hospitalized on nonmarathon dates. (Funded by the National Institutes of Health.).

Endurance Exercise and the Heart: Friend or Foe?

Although low- to moderate-intensity exercise has well-known cardiovascular benefits, it has been increasingly suggested that prolonged strenuous endurance exercise (SEE) could have potential deleterious cardiac effects. In effect, the term 'cardiac overuse injury' (or 'over-exercise') has been recently reported to group all the possible deleterious cardiac consequences of repeated exposure to SEE or 'over-exercise'. In this article, we provide a balanced overview of the current state of knowledge regarding the 'pros' and 'cons' of SEE from a cardiological point of view.

The Nature of Self-Regulatory Fatigue and "Ego Depletion": Lessons From Physical Fatigue

Self-regulation requires overriding a dominant response and leads to temporary self-regulatory fatigue. Existing theories of the nature and causes of self-regulatory fatigue highlight physiological substrates such as glucose, or psychological processes such as motivation, but these explanations are incomplete on their own. Historically, theories of physical fatigue demonstrate a similar pattern of useful but incomplete explanations, as recent views of physical fatigue emphasize the roles of both physiological and psychological factors. In addition to accounting for multiple inputs, these newer views also explain how fatigue can occur even in the presence of sufficient resources. Examining these newer theories of physical fatigue can serve as a foundation on which to build a more comprehensive understanding of self-regulatory fatigue that integrates possible neurobiological underpinnings of physical and self-regulatory fatigue, and suggests the possible function of self-regulatory fatigue.

Sudden cardiac death in marathons: a systematic review

The aim of this systematic review is to summarise the results of cohort studies that examined the incidence of SCD in marathons and to assess the quality of the methods used. A search of the PROSPERO international database revealed no prospective or published systematic reviews investigating SCD in marathons. The review was conducted using studies that reported and characterised the incidence of SCD in people participating in marathons. Studies were identified via electronic database searches (Medline, CINAHL, SPORTDiscus and Google Scholar) from January 1, 1966 to October 1, 2014 and through manual literature searches. 7 studies met the inclusion criteria and were included in this review. 6 of the studies were conducted in the USA and 1 in the UK. These studies covered a 34-year period involving between 215,413 and 3,949,000 runners. The SCD of between 4 and 28 people are recorded in the papers and the reported estimates of the incidence of SCD in marathons ranged widely from 0.6 to 1.9 per 100,000 runners. The proportion of those suffering SCD who were male ranged from 57.1% to 100% and the mean age reported in the papers, ranged from 37 to 48. This review raises 4 methodological concerns over i) collating reports of SCD in marathons; ii) time of death in relation to the marathon; iii) the use of registrants rather than runners in the estimates of sample size and iv) limited detail on runners exercise history. These four concerns all threaten the reliability and interpretation of any estimate of SCD incidence rates in marathons.  This review recommends that the methods used to collect data on SCD in marathons be improved and that a central reporting system be established.

Application of pre-participation cardiovascular screening guidelines to novice older runners and endurance athletes

Objectives:

Despite robust growth in participation in marathons and endurance sports among older individuals, guidance regarding pre-participation cardiovascular evaluation of these athletes is lacking. The objective of this study was to assess the utility of currently available pre-participation cardiovascular evaluation guidelines as applied to a cohort of older novice endurance athletes.

Methods:

We applied data from 1457 novice runners and endurance athletes aged 35 years and older to two pre-participation screening tools, the American Heart Association/American College of Sports Medicine Pre-Participation Questionnaire and the 2001 Working Group recommendations for pre-participation screening of masters athletes (2001 Masters).

Results:

Application of the American Heart Association/American College of Sports Medicine Pre-Participation Questionnaire identified 42.1% for which pre-participation cardiovascular evaluation was indicated. Of those who met criteria, 51.5% reported completion of a healthcare evaluation. Application of the 2001 Masters guidelines identified 75.2% who qualified for pre-participation electrocardiogram and 34.0% for pre-participation stress testing. Of those who met 2001 Masters criteria for pre-participation testing, 43.7% and 24.6% underwent recommended electrocardiogram and stress testing, respectively. While there was modest concordance with recommendations for pre-participation evaluations based on both American Heart Association/American College of Sports Medicine Pre-Participation Questionnaire and 2001 Masters, only athlete age was independently associated with completion of a pre-participation healthcare evaluation and only athlete age and athlete’s participation in marathons were independently associated with pre-participation stress testing.

Conclusion:

Among older novice endurance athletes, application of the American Heart Association/American College of Sports Medicine Pre-Participation Questionnaire and 2001 Masters guidelines identifies a significant percentage of athletes for whom pre-participation evaluation and testing are recommended. Concordance with these guidelines was modest and providers were primarily influenced by athlete age and competitive goals when planning pre-participation testing. Given the rarity of cardiovascular events among older participants in endurance events, the cost-effectiveness of the American Heart Association/American College of Sports Medicine Pre-Participation Questionnaire and 2001 Masters guidelines may be unacceptable for general use.

Fatal water intoxication and cardiac arrest in runners during marathons: prevention and treatment based on validated clinical paradigms

Cerebral edema due to exercise-associated hyponatremia and cardiac arrest due to atherosclerotic heart disease cause rare marathon-related fatalities in young female and middle-aged male runners, respectively. Studies in asymptomatic middle-aged male physician-runners during races identified inflammation due to skeletal muscle injury after glycogen depletion as the shared underlying cause. Nonosmotic secretion of arginine vasopressin as a neuroendocrine stress response to rhabdomyolysis mediates hyponatremia as a variant of the syndrome of inappropriate antidiuretic hormone secretion. Fatal hyponatremic encephalopathy in young female runners was curtailed using emergent infusion of intravenous hypertonic (3%) saline to reverse cerebral edema on the basis of this paradigm. This treatment was arrived at through a consensus process within the medical community. An increasing frequency of cardiac arrest and sudden death has been identified in middle-aged male runners in 2 studies since the year 2000. Same-aged asymptomatic male physician-runners showed post-race elevations in interleukin-6 and C-reactive protein, biomarkers that predict acute cardiac events in healthy persons. Hypercoagulability with in vivo platelet activation and release of cardiac troponin and N-terminal pro-brain natriuretic peptide were also observed post-race in these same subjects. High short-term risk for atherothrombosis during races as shown by stratification of biomarkers in asymptomatic men may render nonobstructive coronary atherosclerotic plaques vulnerable to rupture. Pre-race aspirin use in this high-risk subgroup is prudent according to conclusive evidence for preventing first acute myocardial infarctions in same-aged healthy male physicians. On the basis of validated clinical paradigms, taking a low-dose aspirin before a marathon and drinking to thirst during the race may avert preventable deaths in susceptible runners.