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The habitual level of physical activity of the human race has significantly and abruptly declined in the last few generations due to technological developments. The professional societies and government health agencies have published minimum physical activity requirement guidelines to educate the masses about the importance of exercise and to reduce cardiovascular (CV) and all-cause mortality at the population level. There is growing participation in marathon running by amateur, middle-aged cases with a belief that more intense exercise will give incremental health benefits. Experts have cautioned the nonathlete amateurs about the "exercise paradox" and probable deleterious effects of high-intensity prolonged exercise on CV and musculoskeletal system. The epidemiological studies suggest a "reverse J shaped" relationship between running intensity and CV mortality. The highest benefits of reduction in CV and all-cause mortality are achieved at a lower intensity of running while the benefits tend to get blunted at a higher intensity of running. The physicians should have a balanced discussion with the amateur runners training for a marathon, about risks and benefits of high-intensity exercise, and should evaluate them to rule out the occult coronary disease.
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© 2016 Journal of Clinical and Preventive Cardiology | Published by Wolters Kluwer - Medknow
The habitual level of physical activity of the human race has significantly and
abruptly declined in the last few generations due to technological developments.
The professional societies and government health agencies have published minimum
physical activity requirement guidelines to educate the masses about the importance
of exercise and to reduce cardiovascular (CV) and all‑cause mortality at the
population level. There is growing participation in marathon running by amateur,
middle‑aged cases with a belief that more intense exercise will give incremental
health benefits. Experts have cautioned the nonathlete amateurs about the “exercise
paradox” and probable deleterious effects of high‑intensity prolonged exercise on CV
and musculoskeletal system. The epidemiological studies suggest a “reverse J shaped”
relationship between running intensity and CV mortality. The highest benefits of
reduction in CV and all‑cause mortality are achieved at a lower intensity of running
while the benefits tend to get blunted at a higher intensity of running. The physicians
should have a balanced discussion with the amateur runners training for a marathon,
about risks and benefits of high‑intensity exercise, and should evaluate them to rule
out the occult coronary disease.
Key Words: Cardiovascular mortality, exercise paradox, marathon running, physical activity
Marathon running for amateurs: Benefits and risks
Nitin Burkule1, MD, DM, DNB, FACC, FASE
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DOI: 10.4103/2250-3528.192681
society. The digital revolution about two generations
ago made office work, entertainment, and daily life
chores available at fingertips causing an epidemic of
sedentary behavior.
A multitude of epidemiological studies showed health
and survival benefits of regular physical activity
through exercise and sports.[2‑4] Intuitively, the society
assumes that higher the level of intense physical activity
higher is the health benefit.[5] The highly accomplished
sportsperson in extreme sports are regarded as the
epitome of health. The participation of amateur runners
in highly advertised and sponsored marathon events has
increased 25‑fold in last two decades.[6] Many amateur
runners take up to running in their late thirties, train
vigorously in their leisure time and may be exposing
themselves to overuse musculoskeletal injuries, adverse
cardiac events and addicting effects of exercise‑induced
endorphin release.
Review Article
Marathon running is a rapidly growing sports
hobby among middle aged, non athletic
population. There are diverse views about habitual
high intensity exercise circulated in both scientific
literature and lay press. The physician should analyze
the conflicting data with scientific rigor and take a
balanced view while advising our patients about high
intensity exercise.
PhysIcAl ActIvIty through the Ages
Homo sapiens species evolved about 2.4 million
years ago. For 84,000 generations, human beings
survived in wild as hunter‑gatherers. They required
to perform a variety of daily physical activity just for
survival.[1] The agricultural revolution approximately
350 generations ago ushered in the dawn of
civilization. The human beings as farmers or artisans
continued to be physically active to meet the demands
of earning their livelihood. However, with the advent
of Industrial Revolution, about seven generations ago
there was a great disruptive change in the lifestyle of
the humanity. The machines took over a lot of physical
labor from day‑to‑day life. This resulted in a significant
reduction of physical activity in a large section of the
From the 1Department
of Cardiology, Jupiter
Hospital, Thane,
Maharashtra, India
Received: September, 2016.
Accepted: September, 2016.
Address for correspondence:
Dr. Nitin Burkule, MD, DM, DNB, FACC, FASE,
Jupiter Hospital, Eastern Express Highway, Thane ‑ 400 606,
Maharashtra, India.
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How to cite this article: Burkule N. Marathon running for amateurs: Benefits
and risks. J Clin Prev Cardiol 2016;5:113-24.
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Burkule: Marathon running for amateurs – Benefits and risks
114 Journal of Clinical and Preventive Cardiology ¦ Oct-Dec 2016 ¦ Volume 5 ¦ Issue 4
the greAt dIvIde
The modern society is sharply divided into a growing
number of intense exercise enthusiasts and a much
larger section of highly sedentary individuals.[5]
Marathon running participation has increased[5] from
25,000 runners in 1976 to approximately 2 million
in 2010. The current recommendation of physical
activity, for optimum reduction of cardiovascular (CV)
morbidity and mortality in the society, is 150 min/week
of moderate intensity exercise or 75 min/week of
vigorous intensity exercise.[7,8] The training duration in
the amateur marathon runners far exceeds these public
health recommendations.[9]
The lay press and the scientific literature have both
high‑pitched “alarmist” proclaiming deleterious effect
of intense physical training and “ardent” supporters
claiming incremental benefit. The percentage of
sudden cardiac deaths (SCDs) of the runners during a
marathon is very small and accounts for only 5%–6%
of all SCD in the general population.[10] Although rare,
marathon‑related SCD has got prominent headlines
causing a shock wave in the community.[10] To advise
our nonathlete patients diligently, the physician needs
to review the scientific evidence, mostly coming from
the epidemiological studies, thoroughly and then take a
balanced view.
A PhysIcIAns dIleMMA
The majority of sports‑related SCD (approximately
94%) occurs in individuals older than 35 years.[10] Since
increasing numbers of older people are participating in
city marathon events, the incidence of running‑related
SCD is expected to rise in near future.[10]
Individuals planning to participate in popular city
marathons often consult physicians for advice regarding
preparticipation preventive check‑up and to certify them
fit for endurance sport. Most of the new recruits of the
marathon are middle‑aged, amateur, and leisure time
runners with minimal or no background of regular sports
activity during school or college years. Some of them have
rapidly switched from sedentary life to daily jogging and
may be harboring occult coronary artery disease (CAD)
due to earlier poor lifestyle.[10] Asymptomatic patients
with stable CAD, remote acute coronary syndrome, or
previous coronary revascularization also aspire to take
part in the marathons.
The guidelines for preparticipation screening of athletes
for National and Olympic level competitive sports are
published which offer effective history questionnaires
and highly selective referral for a physical
examination.[11] Routine use of electrocardiogram
and echocardiography is contraindicated due to very
low‑pretest probability and high false positive results.
Recommendations and consensus documents are
published for screening nonathlete amateur runners
with the above‑mentioned clinical profile.[12,13]
Amateur runners who are training regularly may consult
the physician for new onset of symptoms such as chest
pain, easy fatigue, declining performance, dizziness, or
palpitation. The intensity of these symptoms is often
understated due to the effects of high level of endorphin
release during endurance sports. The physician should
carefully evaluate even minimal symptoms in these
middle‑aged runners. Even after diagnosing potentially
hazardous CV condition, the physician is faced with a
challenge to dissuade successfully, the running addicted
patient, from participating in the next marathon.
cArdIAc reModelIng wIth exercIse
High level of endurance sports activity like long‑distance
running cause morphological and functional adaptive
changes in the heart. The “athlete’s heart” syndrome
is a variable extent of morphological and electrical
remodeling in response to the sporting activities such
as endurance (long‑distance running), power (lifting
or throwing heavy objects), or a combination of power
and endurance (cycling and rowing).[14] Its accurate
differentiation from cardiomyopathies is critical.[14]
The upper limits of remodeling of the athlete’s heart
on echocardiography are defined in the literature[14,15]
[Table 1]. Normalizing the cardiac dimensions for body
surface area removes most of the differences between
male and female runners. The eccentric hypertrophy
of left ventricle (LV), increased LV and left atrial (LA)
volume, increased right ventricular (RV) volume, resting
bradycardia, and lower resting LV ejection fraction (EF)
are the typical findings in endurance athletes.[15] They
are considered as physiologic adaptations, and their
upper limits serve to distinguish athlete’s heart from
hypertrophic or dilated cardiomyopathies.[14]
In a cardiac magnetic resonance imaging (MRI) study[16]
of 33 competitive elite male endurance athletes (age
30–60 years) with a training history of 29 ± 8 years,
Table 1: Echocardiographic measurements in male
and female ultramarathon athletes
Dimensions Male athletes Female athletes
LVIDd/BSA 3.8±0.3 (3.2‑4.5) 3.9±0.2 (3.4‑4.5)
IVSd (cm) 1.1±0.2 (0.8‑1.4) 1.0±0.1 (0.6‑1.2)
PWTd (cm) 1.0±0.1 (0.7‑1.2) 0.8±0.1 (0.6‑1.0)
LV mass/BSA 71±13 (39‑105) 66±10 (51‑88)
LAD (cm) 3.7±0.4 (2.6‑4.7) 3.4±0.4 (2.5‑4.1)
LVEDV/BSA 51±10 (26‑90) 55±10 (33‑87)
LVESV/BSA 18±7 (8‑38) 19±6 (8‑33)
EF (%) 64±10 (49‑82) 67±9 (50‑82)
LVIDd=Left ventricle internal dimension in diastole,
BSA=Body surface area, IVSd=Interventricular septum
in diastole, PWTd=Posterior wall thickness in diastole,
LV=Left vascular, LAD=Left anterior descending,
LVEDV=Left ventricular end‑diastolic volume, LVESV=Left
ventricular end‑systolic volume, EF=Ejection fraction. Data
adapted from study by George KP et al.[15]
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indexed LV mass and RV mass and indexed LV
end‑diastolic volume and RV end‑diastolic volume
were significantly higher in athletes as compared with
controls [Table 2]. The RV EF did not differ between
athletes and controls.
In a study[17] of previously sedentary cases (age 25–35 years),
who embarked upon training for a marathon, cardiac
MRI for RV and LV volumes was performed at baseline
and after 3, 6, 9, and 12 months of training. LV and RV
mass increased progressively with training and reached
levels similar to those of elite endurance athletes. LV
initially showed concentric remodeling during the first
6–9 months of endurance training. Thereafter, LV showed
dilatation (eccentric remodeling) and restored the baseline
mass‑to‑volume ratio. The RV responded with eccentric
remodeling at all levels of training. This study gives
insight into the time frame required for training to make
the heart “marathon ready.”
A follow‑up echocardiographic study[18] of 114 Italian
Olympic athletes (78% male; mean age 22 ± 4 years)
undergoing intensive and uninterrupted training
over 4–17 years for 2–5 consecutive Olympic
Games (total 344 Olympic events) did not show adverse
effects of athlete’s adaptive cardiac remodeling. The
global LVEF remained unchanged, and new wall
motion abnormalities were absent. The LV volumes
and LV mass index remained unchanged, and LV
filling patterns remained within normal limits. The
LA dimension showed a mild increase in follow‑up.
Therefore, in young Olympic athletes, extreme and
uninterrupted endurance training, over a long period
did not show deterioration of LV systolic and diastolic
function or progression of LV hypertrophy.
Some experts caution about the overlap of
morphometric values of the athlete’s heart with the
clinical cardiomyopathies and also doubt the assumed
“physiological” nature of the cardiac remodeling in
endurance athletes.[14] In general, compensatory chamber
hypertrophy in cardiac diseases is counterproductive.
The myocardial hypertrophy with myocardial fibrosis
alters the chamber compliance leading to clinical heart
failure and arrhythmias.
benefIts of PhysIcAl ActIvIty
Regular exercise has a lot of pleiotropic health benefits
through positive modulation of plethora of physiological
processes [Table 3]. Exercise at minimum recommended
level positively affects all the modifiable coronary
risk factors,[19] improves CV function,[9] modulates
genomic expression,[1] and reduces the incidence of
malignancies. Exercise promotes psychological health
and improves sleep pattern.
Interestingly, when an individual switch from
sedentary habit to an active lifestyle, a large quantum
of CV benefits, and improved life expectancy is already
Table 3: Pleiotropic benefits of regular exercise
Positive effects of exercise
Modification of CAD risk factors[9,19]
Increase in
HDL cholesterol
Insulin sensitivity
Reduction in
LDL cholesterol
Blood sugar
Blood pressure
Body mass index
Systemic inflammation
Cardiac effects[10,54,66,67]
Improved peak oxygen consumption
Improved diastolic function
Improved stroke volume
Reduce LV compliance
Increase vagal tone
Reduce acute risk of MI and SCD during exercise
Vascular effects[9]
Improve endothelial function
Increase nitric oxide bioavailability
Cause vascular remodeling
Reduce systemic vascular resistance
Improve coronary vasomotor response
Neuropsychological effects[1]
Promote feeling of wellbeing
Reduce depression and anxiety
Improve sleep architecture
Improve sexual drive and performance
Modulates multiple genes expression
Improves immunity
Reduces incidence of malignancies
Reduces circulating adipokines and cytokines
HDL=High‑density lipoprotein, LDL=Low‑density
lipoprotein, MI=Myocardial infarction, SCD=Sudden
cardiac death, CAD=Coronary artery disease
Table 2: Cardiac magnetic resonance imaging
measurements in elite endurance master athletes
and control cases
Dimensions Master athletes Controls
LV mass (g/m2) 96±13 96±13
RV mass (g/m2) 36±7 36±7
LVEDV (mL/m2) 104±13 69±18
RVEDV (mL/m2) 110±22 66±16
RV EF (%) 52±8 54±6
LV=Left vascular, RV=Right vascular, LVEDV=Left
ventricular end‑diastolic volume, RVEDV=Right
ventricular end‑diastolic volume, EF=Ejection fraction.
Data adapted from study by Bohm P et al.[16]
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accrued at the much lower intensity of regular physical
activity.[2,20] Simply standing >2 h/day is associated with
a 10% reduction in all‑cause mortality compared with
standing <2 h/day. The lowest mortality was achieved
in individuals standing >8 h/day.[21] Even 15 min of
brisk walking per day (half of current public health
recommendation) reduced mortality from ischemic
heart disease by 25% and increased life expectancy
by 3‑year.[2] Running only 10 min/day at slow speed
<6 miles/h, weekly running <51 min, <6 miles,
1–2 times, or <506 metabolic equivalents (METS)‑min
are sufficient to substantially reduce risk of mortality,
compared with not running.[3,22] This amount of light
exercise is easily achievable, can cause 30% and 45%
reduction in all‑cause and CV mortality, respectively,
and add 3 years of gain in life expectancy.[3] Data
extracted from 26 cohort studies show that increment
of 1 MET h/week of energy expenditure, which
is equivalent to 2–3 min of moderate to vigorous
physical activity per day, results in a 0.8% reduction
of the average relative risk (RR) of mortality from
noncommunicable diseases.[23] The Japanese Public
Health recommendation of daily 10+ min of moderate
to vigorous activity, of any nature, aims at reducing RR
by 3.2% at the population level.[23]
Both brisk walking and running can achieve an
equivalent level of reduction in CV events except that
the time spent in walking should be 2–4 times that of
running.[24] Walking is much easier to perform daily, is
sustainable and safe with regards to musculoskeletal
injuries, and gives an opportunity for social networking.
Young individuals with busy lifestyle and time crunch
can achieve significant CV benefits by short bouts of
running even 10 min a day 3–4 times, less than an
hour per week.[22,24]
The relation of CV mortality reduction and quantum of
physical activity is not linear but curvilinear.[2,9] This
observation suggests that at a higher level of exercise
further gain in CV benefits is less or may plateau for
every additional METS of exercise performed.[3,4] It
is unclear whether there is a ceiling dose of exercise.
According to some experts, there is no significant
benefit beyond 9 METS of exercise in women and 10
METS of exercise in men per session[6,25] or 3–10 times
the recommended physical activity level[4] or beyond
120 min/week of exercise.[3] Even among the extremely
active Ache Hunters of Paraguay, who had much
superior cardiorespiratory fitness than people in
developed world, the average daily distance covered
for aging was approximately 6 miles.[1] A moderate
range of intensity, frequency, and duration of exercise
may be important for maximizing health and longevity
benefits.[6] The human race has been evolutionarily
adapted to a variety of physical activities performed
intermittently at moderate intensities for moderate
durations and not to just one type of endurance activity
like long distance running.[1]
the exercIse PArAdox
It seems that the first marathon run claimed a life! In
490 B.C. Pheidippides, the Greek professional courier,
ran from Marathon to Athens and declared the Greek’s
victory over Persians saying “Nike” and then collapsed
and died.[20] However, historians think that it is a myth
and in reality Pheidippides further continued to run to
Sparta to carry the message for military help.[26]
There is sufficient evidence to suggest that there is a
short‑term rise in myocardial infarction (MI) and SCD
during the hour‑long period of exercise and recovery
than during the rest 23 h when the individuals are
less active.[27,28] The risk of MI with each bout of
physical activity is approximately doubled even for a
fit individual who regularly performs vigorous exercise
5 times a week.[5] However, the RR of MI during intense
physical activity is 50 times higher in habitually
sedentary individuals who suddenly get engaged in
exercise bout than the individuals who are regularly
performing moderate to high level of exercise.[29] The
overall RR of SCD within 30 min of vigorous exercise is
seven‑fold higher in those who exercise less than once
per week as compared to those who exercise >5 times
per week.[30] Although exercise increases the acute
risk of SCD and MI, paradoxically “regular” exercise
of moderate to high intensity is highly protective
and reduces the exercise induced the risk of SCD by
7–10‑fold and of MI by 50‑fold.[10]
The risk of SCD during marathon events is as small
as 0.8–2/100,000 marathon runners and the risk of
all sports‑related SCD is as insignificant as 4–5/1
million population of the nation.[31,32] In a marathon,
runners >30 years of age, approximately 80% of
SCD are caused by atherosclerotic CAD.[11,31] In this
age group, a small fraction of SCDs are attributed to
cardiomyopathies, myocarditis, congenital coronary
anomalies, trauma, heat stroke, or channelopathies.[11]
For leisure time joggers, the annual incidence of SCD
is higher than marathon events (13 SCD per 100,000
joggers per year).[33] Their imaging and autopsy
studies reveal nonobstructive coronary plaques, with
a thin cap ruptured in the center of the plaque, with
large overlying thrombus.[10] This suggests a role of
hemodynamic shear force on the vessel wall and
adrenergic hypercoagulable state during intense and
prolonged exercise.
The epidemic of atrial fibrillation (AF) in the later
part of life is increasingly viewed as lifestyle disease.
There is a strong evidence to suggest that middle‑aged
individuals who are habitually physically active have
a lesser incidence of AF in the later part of life.[34,35]
Exercise effectively controls the risk factors for AF such
as hypertension, obesity, and obstructive sleep apnea
and prevent age‑related decline in LV compliance.
For every 1‑MET increase in cardiorespiratory fitness
level, there is an associated 7% decrease in the risk of
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A F. [36] Paradoxically, individuals engaged in an extreme
level of sports activity in the early part of life have
a higher incidence of AF in the later part of life. In
a study[34] of 44,410 Swedish men, intense exercise
of more than 5 h per week at the age of 30 years
increased the risk of developing AF later in life. In
contrast, moderate intensity of physical activity such
as walking or bicycling, in the middle age, decreased
the risk of AF.
The increased risk of AF is thought to be mediated
through adaptive cardiac remodeling such as
LA dilatation due to increased cardiac output,
increased atrial conduction time, LA fibrosis, and
resting bradycardia with intermittent exposure to
high‑catecholamine levels with training.[36]
chAllenges of InterPretIng ePIdeMIologIcAl
studIes of PhysIcAl ActIvIty
Population‑based epidemiological studies of physical
activity have given unambiguous scientific evidence
of a reduction in all‑cause mortality and CV mortality
with an active lifestyle.[19,25,37] One should be aware of
certain aspects and limitations of these studies. It is
highly challenging to measure exact exercise dose at
the individual level. There is no standard definition
of what constitutes an athlete, intense exercise,
or endurance exercise.[38] Change of lifestyle from
sedentary to active promotes incremental health and
feeling of well‑being in an individual. The healthier
individual in turn is likely to exercise more, thus
blurring or confounding the simple exercise dose and
health effect relationship.[24]
Most of the studies rely on cases’ self‑reporting of
exercise with regards to perceived intensity, time
duration per session, and frequency per week. From
this data, a parameter called “METS‑hour per week”
of energy expenditure is calculated which is a product
of predicted METS per unit time for the kind of
exercise × time duration per session × frequency per
week.[9] Moderate intensity activities are 3.0–5.9 METS,
whereas vigorous activities are >6.0 METS. However,
the definition of intense exercise used in the cardiology
literature is 10 METS which may be perceived as
a warm‑up for elite competitive athletes.[38] Even in
amateur runners, the perceived intensity of similar
jogging pace may be “strenuous’” for a deconditioned
middle‑aged man while it may be “light” for a young
active teen.[39]
There are also significant differences between amateur
runners and the elite athletes.[6] The athletes start their
strenuous exercise program in first or early second
decade of life before the significant atherosclerotic
process can start in the coronaries. It is highly
likely that they are genetically endowed for physical
excellence. They exercise under professional guidance
for exercise technique, cross training, and diet. They
maintain overall healthy lifestyle and take adequate
rest for the healing of overuse injuries.[6] Postcareer,
they systematically reduce the training intensity and
duration. In the developed world, athletes maintain
high standards of living and have access to medical
care which can also contribute to increased longevity.
For the same reason of high standards of living,
even Nobel Prize or Oscar Award winners have a
superior life expectancy as compared to the general
In contrast, amateur runners are lay people who
take up running in middle age when the occult
atherosclerotic process may have already set in.
Professional athletes usually perform >80% of their
training sessions at subjectively light intensities (50%–
70% of their maximal heart rate) compared with novice
runners who often train relatively and subjectively at
too high intensities.[40] In fact, numerous middle‑aged
and poorly prepared runners start strenuous
running programs immediately after CV disease
diagnosis.[40] Although many nonathletic people get
addicted to running, not all of them stop smoking
or make healthy dietary choices.[27] Many of them,
during training, drink excess of insulin spiking and
high‑carbohydrate energy drinks. Most of them enter
into grueling training schedule without compromising
their working hours but add their exercise schedule
to the demands of a job, marriage, and parenting.
There is no adequate rest period for healing overuse
injuries such as plantar fasciitis, Achilles tendonitis,
shin splints, and patellar chondromalacia.[6] Not all
of them have easy access to professional exercise
trainers and higher medical care. Hence, increased
longevity data of athletes cannot be extrapolated to
amateur runners just because they are engaged in the
same kind of physical activity.
There are also a difference in leisure time running
and marathon training for amateur runners. The
leisure time running is noncompetitive with adequate
time to relax. While marathon training as referred
to earlier is competitive, arbitrarily structured,
and compromises adequate rest in busy, working
individuals. Novice amateur runners may fail to
optimize their running performance and CV health
by blindly following modern training methods used
by elite athletes.[40]
The epidemiological studies of jogging divide the
observational cohort into different groups, namely
sedentary controls, predefined mild, moderate, high,
and extremely high levels of joggers. In general
population, a number of individuals in the groups at
high to extremely high level of habitual exercise are
distinctly underrepresented. Small events of all‑cause
mortality in these groups get proportionately magnified
with wide confidence intervals (CIs).
With these limitations in mind, let us explore the
evidence of health benefits and hazards with the
increasing dose of running.
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Is there A hArM wIth hIghIntensIty exercIse?
The view
Few animal experiments (marathon rats) and some large
population‑based observational studies have indicated
deleterious effects on the heart with high‑intensity
prolonged exercise. “Cardiac fatigue” is a phrase coined
to describe transient functional and biochemical
changes in myocardium after extraordinary endurance
events[41] [Table 4]. The theoretical hazards involved
with intense exercise are as follows:
• Increased troponin and B‑type natriuretic
peptide (BNP) release[42] was noted during marathon
running suggesting myocardial injury, which
may compound over time to cause myocardial
fibrosis. In Boston Marathon Study[42] of sixty
nonelite participants, at the end of the race, 60%
had increased troponins above the 99th percentile
of normal and 40% had troponin levels above the
diagnostic threshold for MI. Compared with athletes
training 45 miles/week, athletes who trained
35 miles/week demonstrated higher troponins and
• In ultra‑endurance triathlon participants,
reduced LVEF, reduced LV fractional shortening,
and segmental wall motion abnormalities in a
nonvascular distribution have been documented on
echocardiography, immediately after the race.[43,44]
The biochemical and functional abnormalities of
LV and RV may last 3–17 h after endurance
events.[45] Increased myocardial fibrosis and
increased susceptibility to arrhythmia are seen in
experimental marathon rats[52]
• Transient RV dilatation and dysfunction and rise
in pulmonary artery pressure are documented in
marathon[14] and triathlon athletes.[45] A cardiac
MRI study[53] reported that marathon running
caused acute dilation of the right atrium and the
right ventricle, reduction in the RV EF, parallel
with elevations in cardiac troponin I and BNP.
Extraordinary endurance exercise may cause acute
fatigue of cardiac muscles, which seems to be more
prominent in the right than the LV.[54] However, this
recovers quickly even after a very long event. The
repetitive postexercise RV abnormalities may have
potential to cause permanent RV injury, fibrosis, and
risk of arrhythmias[55,56]
• Cardiac MRI has shown increased incidence
of late gadolinium enhancement (LGE) in both
coronary (subendocardial) and noncoronary (septal
insertion sites) distribution in endurance athletes.[9]
Almost half of older lifelong endurance athletes had
shown evidence of myocardial fibrosis, whereas
age‑matched controls or young athletes had no
fibrosis on LGE‑MRI.[46] The cause may be acute
myocardial injury, myocardial edema[54] leading to
permanent septal or RV fibrosis with putative future
arrhythmic risk
• In a study[47] of 108 healthy, middle‑aged (50 years)
marathon runners, cardiac computed
tomography (CT) showed a higher level of coronary
artery calcium score (CAC) compared to Framingham
risk score‑matched population but a similar level of
CAC compared to age‑ and sex‑matched sedentary
population. This population is representative of
typical amateur runners since they started training
within the preceding decade and their exercise
training volume was relatively modest. More than
half of these cases were previous smokers, and
their body mass indices were at the higher end of
normal range. Thirty‑six percent of these marathon
runners had CAC score 100 or more and 9% of
these required coronary revascularization during
2 years of follow‑up indicating no protective effect
of running for atherosclerosis in late life[54]
• LGE was observed in 12% of these athletes.
CAC percentile values and number of marathons
independently predicted the presence of LGE.
Runners with LGE had higher subclinical CAD
Table 4: Probable adverse effects of long‑term,
high‑intensity exercise
Myocardial fatigue and injury[42‑45]
Release of cardiac injury biomarkers troponin, BNP
Increased incidence of myocardial edema on cardiac
Transient LV regional wall motion abnormality
Transient RV systolic dysfunction and dilatation
Cardiac morphological effects[9,16,46]
Progressive LA dilatation and fibrosis
Eccentric LV hypertrophy and RV dilatation
Increased incidence of myocardial fibrosis on cardiac
Coronary vascular effects[27,30,47,48]
Increased coronary calcium score
Acceleration of established atherosclerosis
Rupture of vulnerable plaque
Acute MI and SCD
Increased incidence of atrial fibrillation in late adulthood
Increased risk of arrhythmia due to electrolyte imbalance
and heat stroke
Increased phenotypic expression of RV cardiomyopathy in
patients with desmosomal mutation
Musculoskeletal injuries[1,6]
Plantar fasciitis
Achilles tendonitis
Shin splints
Patellar chondromalacia
Spine osteopenia
LV=Left vascular, RV=Right vascular, MI=Myocardial
infarction, SCD=Sudden cardiac death, LGE=Late
gadolinium enhancement, MRI=Magnetic resonance
imaging, LA=Left atrial, BNP=B‑type natriuretic peptide
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burden and had higher increases in troponin I
during marathon, suggesting a causal relationship.
Higher CAC scores and LGE are shown to be
associated with higher coronary event rates on
long‑term follow‑up.[53,57] Some marathoners may
have higher levels of CAC due to an increase in
PTH levels during running[54]
• A study[48] comparing coronary angiograms
of marathon runners with that of sedentary,
age‑matched controls showed that male
veterans (who ran at least one marathon each year
for 25 consecutive years) had significantly increased
amounts of both hard and soft coronary plaques. It is
unlikely that the high‑dose vigorous exercise causes
atherosclerosis but it may potentiate the existing
atherosclerosis process by increasing repetitive
arterial shear stress and chronic pro‑inflammatory
• Significantly higher incidence of late‑life AF is
seen in individuals participating in prolonged
high‑intensity exercise in the early part of life. In a
rat model,[52] chronic endurance exercise increased
AF susceptibility due to autonomic changes,
increased vagal tone, atrial dilation, and fibrosis. In a
Swedish study,[49] 52,755 participants in Vasaloppet,
a 90 km cross‑country skiing event, from the year
1989 to 1998 were followed up until the year
2005. AF and bradyarrhythmias were experienced
by 919 participants. A faster finishing time and a
high number of completed races were associated
with higher risk of AF. In a meta‑analysis[50] of
six case–control studies of 655 athletes and 895
controls, AF was documented in 23% of athletes
and 12.5% in controls. The odds ratio (OR) for AF
in the athlete group was 5.29 (95% CI 3.57–7.85).
In a study[58] of 115 cases of athletes with AF,
compared with 57 age‑matched controls, the OR
for new AF was 4.52 for cumulative heavy sports
activity (>2000 h) which was almost equivalent to
cases with sleep apnea (OR 5.04) and higher than
even sedentary individuals (OR 3.85)
• Majority of SCD occur in full marathons than in
half marathons and that too strikingly in the final
quartile of full marathons.[10] The cause may be
multifactorial such as sympathetic overactivation,
electrolyte imbalance, activation of hemostatic
system, shear stress on vulnerable coronary plaques,
or hemorrhage into the plaque.[10] The heat stroke
may be a major cause of SCD during endurance
running events[51]
• The risk of myocardial biomarker release, acute
MI, and SCD during marathon running or training
is higher in poorly trained marathon runners
as compared to highly trained athletes. The
musculoskeletal injuries with running are common
and can be severe enough to stop participation in
aerobic exercise. In an 8‑week training session
for 4 miles run, 25% of participants developed
significant musculoskeletal injuries requiring
cessation of training[59]
• Among individuals who carry a desmosome
mutation for RV cardiomyopathy, the endurance
training can cause deterioration of RV function
and accelerate the phenotype expression of RV
The counter view
Except for higher incidence of AF, there is no clear
evidence of highly significantly increased the risk of
ventricular arrhythmias, heart failure, CV, or all‑cause
mortality in endurance athletes and active individuals
from epidemiological studies.[19] The risk for SCD from
running is negligible and is as low as 4/1 million.[60]
The elite athletes have fewer hospitalizations, require
less asthma, CV, and anti‑inflammatory medications,
and live longer than nonathletic people.[27] In
Vasaloppet, the 90 km cross‑country skiing event,
there was no increase in ventricular tachycardia,
ventricular fibrillation, or cardiac arrest.[49] The
cross‑country skiers had 52% reduction in all‑cause
mortality, with the highest life expectancy found
in older participants and athletes who participated
in multiple races.[61] More than 15,174 Olympic
medalists from nine different country groups
were followed up over decades after their first
medal.[54] The participants of the endurance sports
had higher survival (2.8 years) compared to age‑ and
sex‑matched controls from the general population
in those countries.[62] Finnish skiers and world‑class
endurance athletes demonstrated an increased life
expectancy of 2.8–6 years compared with reference
cohorts.[63‑65] Masters athletes, who had been training
for more than 25 years, competing successfully in
multiple marathons, triathlons had LV compliance,
vascular age, and vasodilatory function similar to
young adults.[54] Their ventricular–arterial coupling
was superior so that they could increase more than
two times their stroke volume for any given increase
in left ventricular filling pressure.
Commencing from 1986, a 22 years long, biennial
questionnaire‑based follow‑up study[19] of 44,551 men,
aged 40–75 years, showed that increasing amounts of
vigorous activity remains inversely associated with
CV and malignancy disease risk. This relationship
existed even among men in the highest categories of
intenseexercise.Running≥5haweek was associated
with the lowest CV risk. Vigorous intensity of exercise
at 10 METS h/week further reduced mortality by
4% points over the moderate intensity of exercise of
identical energy expenditure. A recent study[66] showed
that the committed exercisers, who have trained
regularly, 4–5 days a week for most of their adult
lives, have ventricles that are almost as compliant as
those of master athletes. In contrast, casual exercisers,
who trained not more than 2–3 times per week, had
no apparent benefit in terms of LV compliance.
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120 Journal of Clinical and Preventive Cardiology ¦ Oct-Dec 2016 ¦ Volume 5 ¦ Issue 4
Recreational marathon training reduces CV risk
factors (obesity and lipid levels) and increases CV
efficiency (improved peak oxygen consumption and
diastolic function).[67]
Both views, for and against habitual strenuous exercise,
should be interpreted cautiously and should not be
used indiscriminately to dissuade strenuous physical
activity in trained, healthy athletes or to encourage
strenuous physical activity in ill‑trained amateur
the reverse J shAPe relAtIonshIP of runnIng
And MortAlIty
The epidemiological studies in general population
studying the relationship of the quantum of running
and mortality reduction consistently show a reverse J
shape pattern.[3,4]
In the Copenhagen City Heart Study,[20] 1098 healthy
joggers and 3950 healthy nonjoggers were prospectively
followed up since 2001. Joggers were categorized as
light (n = 576), moderate (n = 262), and strenuous
joggers (n = 40) depending on the combination
of self‑reported pace (slow, average, and fast),
quantity (<2.5 h/week, 2.5–4 h/week, and >4 h/week),
and frequency (<3 times/week, >3 times/week). For
example, a case with slow or average pace jogging for
<2.5 h/week and <3 times/week will be categorized as
“light jogger” whereas a case with fast pace jogging for
>2.5 h/week and >3 times/week will be categorized as
“strenuous jogger.” The lowest hazards ration (HR) for
mortality was found in light joggers (HR: 0.22; 95%
CI: 0.10–0.47), followed by moderate joggers (HR: 0.66;
95% CI: 0.32–1.38) and strenuous joggers (HR: 1.97;
95% CI: 0.48–8.14). Jogging up to 2.5 h/per week at a
slow or average pace and a frequency of <3 times per
week was associated with the lowest mortality. Those
who jogged >4 h/week, at a fast pace, and >3 times/
week appeared to lose many of the longevity benefits.
In other words, light and moderate joggers have
lower mortality than sedentary nonjoggers whereas
strenuous joggers have a mortality rate not statistically
different from that of sedentary nonjoggers (U‑shaped
association). The study was criticized for nonobjective
“self‑reporting” of pace[39] and low number of strenuous
joggers exaggerating the HR in this group (n = 40
with two deaths). Similar reverse J shape findings for
intensity and duration of exercise were not found in the
studies of walking and cycling by the same authors.[68,69]
Cooper Clinic in Dallas, Texas, followed up of 55,137
adults for 15‑year to examine associations of running
with all‑cause and CV mortality.[3,22] They used five
quintiles of running so there would be an equal number
of cases across different doses of running. CV mortality
appeared to be relatively higher in those with higher
doses of running compared with lower doses (reverse
J‑shaped association) and a slight nonsignificant trend
of less benefit, for all‑cause mortality, with higher doses
of running compared with lower doses of running.
However, there continued to be significantly lower
risks of mortality in the highest quintiles of running
time (>176 min/week) and frequency (>6 times/week)
compared to the nonrunners (no U‑shaped association).
Despite all the limitations of methodologies in
these studies, few distinct trends emerge, which are
hypothesis generating [Figure 1]. More is definitely
not better[22] but may not be harmful.[3,22] The benefit
of maximal reduction in mortality is achieved at light
to moderate intensity of regular jogging as compared
to habitual sedentary behavior. There is no further
reduction in mortality with a higher dose of jogging but
rather the benefits tend to get blunted or reduced at a
higher intensity or extreme level of running.
The reverse J shape relation of exercise and mortality
has also been shown in post‑MI patients and patients
with stable CAD. In a study[70] of 2377 MI survivors, 15%
average risk reduction in CV mortality was achieved for
every additional 1 MET h/day of exercise (equivalent
of running 1 km/day) only till 7.2 MET h/day. Regular
exercise above this level, in this post‑MI population,
did not benefit but rather increased CV events. Relative
to the CV risk reduction at 7.2 MET h/day exercise, the
CV risk of exercising above 7.2 MET h/day increased
3.2‑fold. In another study of 1038 cases[71] with stable
CAD, the frequency of strenuous leisure time physical
activity was assessed over 10 years of follow‑up. The
CV events, mortality, and all‑cause mortality were
highest in the sedentary group and then progressively
declined from infrequent (1–4 times a month) to
moderate activity (2–4 times a week) groups. However,
the CV events, CV mortality, and all‑cause mortality
again climbed progressively in the frequent (5–6 times
Figure 1: Conceptual graph of the approximate relationship of “intensity
of jogging” (time, distance, speed, frequency, and metabolic equivalents
min/week) and reduction in “cardiovascular mortality” derived from data of Lee
et al. [3] showing reverse J shape. There is significant reduction in cardiovascular
mortality at the lower quintiles of running intensity, while the benefits appear
to get blunted at higher quintiles of running intensity
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Journal of Clinical and Preventive Cardiology ¦ Oct-Dec 2016 ¦ Volume 5 ¦ Issue 4
a week) to daily strenuous activity group. The all‑
cause mortality rate per 1000 persons‑year was 44.3 in
sedentary group, 14.1 in infrequent activity (1–4 times
a week) group, 7.6 in moderate activity (2–4 times a
week) group, 8.7 in frequent activity (5–6 times a week)
group, and 16.2 in daily strenuous activity group.
It is controversial and probably not true that
individuals lose all the benefits of exercise at habitual
high or extremely high intensity of exercise and the
mortality climbs back to that of sedentary level[22] (the
U‑shaped relation). Therefore, the strenuous level
of running is not better for sure but not necessarily
harmful.[27] A weekly cumulative dose of vigorous
exercise of not more than 5 h may be the safe upper
range for optimal CV health and life expectancy. It
may be beneficial to take 1 or 2 days a week off from
vigorous exercise and not to perform high‑intensity
exercise on a daily basis.[6]
screenIng of AMAteur runners
The preparticipation electrocardiography (ECG)
screening of young athletes is controversial considering
financial and logistics cost of ECG acquisition and
interpretation, high rate of false‑positive findings,
cost of follow‑up testing after abnormal ECG, and
the problems of future insurability of athletes with
abnormal ECG.[72] However, the risk of SCD in older
athletes is 5‑fold higher during training than during
the marathon event.[10] The physician has to diligently
screen for occult CAD in the sedentary individuals,
above the age of thirty, who wish to first‑time start
training for a marathon. There are three published
documents for preparticipation screening of the older
athlete for risk stratification.[12,13,73]
A comprehensive history as outlined in the
questionnaire[74] is very useful to detect patients
needing detail physical examination and ECG [Table 5].
A high‑risk case can be identified by clinical features[10]
For example, strong family history of premature CAD
or SCD, Framingham risk score >5%, high‑body
mass index, high‑LDL cholesterol, or diabetes with
microalbuminuria. When the patient has high‑CAD
risk profile and the gap between his/her daily
physical activity and planned training level is large,
the physician should perform a maximal stress
test.[10] The incremental value of the selective use of
echocardiography, cardiac MRI, or CT coronary calcium
score is not defined in this population.
counselIng of the AMAteur runners
Physicians should have a detail and balanced discussion
with the amateur runner training for the marathon.
Most of these individuals are performing physical
activity far more than the minimal recommendations
for the society.[27] It should be made clear that exercise
benefits far outweigh the risks at every level of
exercise. Although no optimal dose of exercise exists,
the maximal CV benefits are already achieved at a
moderate intensity of exercise. Although the routine
performance of high level of exercise bestows relative
protection from CV mortality, unfortunately no level of
exercise gives complete immunity from CV disease or
mortality.[27] The higher level of training does not mean
better CV benefits. Higher running dose is associated
Table 5: Preparticipation self‑assessment
questionnaire for amateur runners
Questions Response
History of
Heart attack
Heart surgery
Cardiac catheterization or
Coronary angioplasty
Heart rhythm disturbance
Pacemaker/implantable cardiac
Heart valve disease
Heart failure
Congenital heart disease
Musculoskeletal problems
Heart or blood pressure
Heart transplantation
If any one point is tick
marked, please consult
physician before
starting training
Symptoms of
Chest discomfort with exertion
Breathlessness with exertion
Dizziness, fainting, and
blackouts with exertion
If any one point is tick
marked, please consult
physician before
starting training
CV risk factors
Male >45 years
Woman >55 years or
posthysterectomy or
Blood pressure >140/90
Blood pressure never measured
Total cholesterol >240 mg/dl
Cholesterol level never
Heart attack <55 years
in father or brother or
age<65 years in mother or
Diabetes mellitus
Physically inactive (<30 min
of physical activity<3 days/
If any two points are
tick marked please
consult physician
before starting training
CV=Cardiovascular. Questionnaire adapted from
recommendations by Balady GJ et al.[74]
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122 Journal of Clinical and Preventive Cardiology ¦ Oct-Dec 2016 ¦ Volume 5 ¦ Issue 4
with higher level of cardiorespiratory fitness, but this
does not translate into better survival (which already
peaks at low dose of exercise).[6] The exercise paradox
must be discussed when counseling both habitual
sedentary individuals and also the exercise enthusiasts.
The inherent risks and benefits of high‑dose exercise
should be made clear.[27] This is especially more
relevant for patients with established stable CAD. The
marathon running may be looked upon as thrilling or
adventure sport and not as ideal workout for maximal
health benefit.
The importance of gradual increment in training
should be emphasized in middle‑aged runners to
avoid precipitation of SCD,[28] acute coronary events,
or musculoskeletal injury. A gradually incremental and
long‑term training schedule may reduce the risk of SCD
substantially in the habitual sedentary cases.[10] The
frequency of physical activity (not the intensity) should
be emphasized as the initial goal. The previously
inactive person should start with brisk walking
3–4 times a week and then upgrade to light pace
jogging at 50%–75% of age‑predicted maximum heart
rate (MHR), and finally to moderate pace running at
70%–85% of age‑predicted MHR. Each stage should last
for 6–8 weeks.[10] As described earlier, exercise‑induced
cardiac adaptive remodeling is a slow process and
takes 9–12 months of training to reach its maximal
The amateur runners should be instructed to observe
even mild symptoms of chest pain, dizziness, small
decrements in exercise capacity, or new onset
fatigability and should seek physician’s consult.[27] This
must be especially more emphasized in patients with
established stable CAD. The amateur runners should
be made aware of the importance of cross training to
achieve maximal aerobic fitness and avoid overuse
injury.[1] The amateur runners must be instructed
to stick to the healthy lifestyle including healthy
dietary choices, quitting smoking, and excess alcohol
consumption.[27] Although statins are prescribed
for eligible patients in accordance with 2015 ACC/
AHA guidelines, the statin‑induced myalgia is often
more troublesome in the runners.[10] The use of
low‑dose aspirin (75–100 mg) as primary prevention
in middle‑aged runners with traditional coronary risk
factors is uncertain,[54] but the benefit may outweigh
the risk.[10]
wIsdoM of hIPPocrAtes
After reviewing the of emerging data of exercise and its
effects on health, the following quote from Hippocrates
appears to be more relevant than ever.[75]
“If we could give every individual the right amount
of nourishment and exercise, not too little and not
too much, we would have found the safest way to
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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... During the last decade, recreational and long-distance running (i.e., half-marathons, marathons, and ultramarathons) have gained great popularity, with the number of participants and races increasing year after year (Burkule 2016;Predel 2014). Runners have a lower risk of all-cause and cardiovascular disease mortality compared with nonrunners while persistent running over time is associated with mortality reduction (Lee et al. 2014). ...
... Runners have a lower risk of all-cause and cardiovascular disease mortality compared with nonrunners while persistent running over time is associated with mortality reduction (Lee et al. 2014). However, longdistance running can pose challenges to a runner's cardiovascular system and it has been associated with a higher risk of acute cardiac events, especially in untrained runners, who are less physically fit (Burkule 2016;Predel 2014) compared with professional athletes. Moreover, this risk increases as the length and the number of races rise (Tunstall Pedoe 2007). ...
... Well-balanced diverse diet with adequate nutrient intake promotes achievement of training goals, supports tissue growth and adaptation, and enables appropriate postexercise recovery (Thomas et al. 2016). In addition, antioxidative nutrients have received significant attention in the field of sport nutrition over the last few decades, since scientific evidence accumulated linking strenuous physical activity with increased risk of acute cardiovascular events (Burkule 2016). The assessment of self-reported dietary intake in our study revealed that a substantial number of examinees had inadequate intake of nutrients possessing antioxidative properties, with particular emphasis on copper and vitamin C. ...
Long-distance running, especially in non-professional runners, can increase cardiac arrest risk by enhancing platelet activation and aggregation. Polyphenols can exert cardioprotective effects by positively influencing platelet function. This study aimed to examine the acute effects of polyphenol-rich aronia juice consumption, before simulation of a half-marathon race, on platelet activation and aggregation with leukocytes in recreational runners. In this acute crossover study,10 healthy male runners (age 30.8 ± 2.3 years) consumed breakfast with 200 mL of aronia juice or 200 mL of placebo. They warmed-up and ran a simulated half-marathon race (21.1 km). Blood was collected at baseline, and at 15 min, 1 h, and 24 h after the run. All variables were analyzed with 4 (time) × 2 (group) ANOVA with repeated measures on both factors. Results revealed a significant effect of group on platelet activation parameters: P-selectin and GPIIb-IIIa expressions significantly decreased in the aronia group compared with the placebo group (F [1,9] = 10.282, p = 0.011 and F [1,9] = 7.860, p = 0.021, respectively). The effect of time was significant on both platelet aggregation markers: platelet-monocyte and platelet-neutrophil aggregates were significantly lower after the race (F [3,7] = 4.227, p = 0.014 and F [3,7] = 70.065, p = 0.000, respectively), with changes more pronounced in the later. All effects remained when platelets were exposed to an agonist. These results suggest that aronia consumption could counteract the half-marathon race-induced changes in platelet function. Novelty Aronia juice consumption significantly decreased the expression of platelet activation markers but did not affect platelet aggregation. The race itself did significantly reduce platelet-neutrophil aggregation. Aronia juice may serve as a supplement beverage for recreational runners to alleviate enhanced platelet reactivity caused by prolonged running.
... 10 Previous studies have shown that the health risk management of amateur marathon runners is related to health belief and health risk prevention behaviors. 11 The health belief model (HBM) is a health education model that changes individual behavior by intervening in perceptions, attitudes, and beliefs, as well as being the most prominent social behavior model with which a series of health risks can be avoided. 12 Specifically, it is the individual's belief in the perceived susceptibility and severity of the health problems that will be encountered, encouraging people to adopt health protection and preventative behaviors. ...
... However, to popularize the health risks and preventive measures related to marathon events, more scholars in the fields of sports management and public health are required to offer insight and empirical evidence. 11 To strengthen amateur marathon runners' awareness of health risks, it is necessary to improve their risk perception levels. For example, the management department should inform the runners who are prone to exercise diseases, respiratory diseases, and blood circulatory diseases through announcements, advertisements, or educational materials about the prevalence and symptoms of these diseases. ...
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Introduction: Prevention of the health risk of amateur marathon runners is of great significance for the sustainable development of marathon. To reduce the psychological burden of amateur marathon runners and improve the participation experience, the current study used the health belief model to study the relationship among health beliefs, attitude to preventative behavior, self-efficacy, and health values of amateur marathon runners. Methods: A total of 342 data were collected, and using the PROCESS (analytical procedures developed for mediating and moderating effects tests based on SPSS and SAS). A series of multiple linear regression models were established to study the relationship between variables, and the bootstrap confidence interval was selected to test the mediating and moderating effect. Results: The results showed that perceived health threat (b = 0.463, p <0.05), health behavior expectations (b = 0.373, p <0.001), self-efficacy (b = 0.322, p <0.001), and behavioral attitudes (b = 0.230, p <0.001) can be regarded as antecedent variables for predicting preventative behaviors. In addition, the results also show that health behavior expectations, self-efficacy, and behavioral attitudes play chain-mediating role between perceived health threat and preventative behaviors. Health values appear to play a moderating role in the direct/indirect effects of perceived health threat on preventive behavior through a number of mediating variables. Discussion: This study emphasizes that the amateur marathon runners must improve their health concept and take effective preventive measures before participating in the competition. According to this research, it is the responsibility of the event parties, public health officials and relevant departments of the host city to provide rich health information and risk education to amateur marathon runners. More public service advertisements or educational materials are needed to be placed on runners to enhance their awareness of the necessity and importance of taking preventive measures.
... Marathon running is a rapidly developing hobby among nonathletic middle-aged people. [1] Non-professional marathon runners and those with limited talent are referred to as amateur marathon runners. In amateur marathon runners, running is linked to a high rate of injuries. ...
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Background: Marathon running is becoming more popular among middle-aged people who have no prior running experience. Improper or incomplete knowledge increases the risk of injuries in amateur runners. Individuals with spinal instability experience alteration in balance control while walking as well as running which in turn results in asymmetrical bodyweight distribution throughout the lower extremity. This changes the pattern of running leading to injuries of hips, knees, and ankle. Methods: The objective of the study was to correlate spinal instability with ankle injuries in amateur marathon runners. In this study, both male and female amateur marathon runners between the age group of 20 and 45 years with normal body mass index (BMI) were chosen and individuals with the previous surgery as well as degenerative diseases of spine and ankle fractures were ruled out. Spinal instability tests were carried out on amateur marathon runners with symptoms of instability. Subjects were asked questions related to ankle injuries. Outcome measures used were Oswestry Disability Index (ODI) and tests for spinal instability. Results: About 57% of participants were tested positive for the passive lumbar extension test and 42% of participants were tested positive for the prone instability test. There was the presence of ankle pain (68%), ankle swelling (24%), heel pain (60%), blisters (42%), ankle sprain (28%), and strain (26%) in selected participants. There were 68% runners with minimal disability and 32% runners with moderate disability. Conclusion: Amateur marathon runners with spinal instability had the presence of ankle injuries like ankle pain, ankle swelling, heel pain, blisters, ankle sprain, and strain. Based on the test performed and interpretation of the ODI and after correlating spinal instability with ankle injuries, we concluded that spinal instability increases the risk of ankle injuries in amateur marathon runners.
... The risk of myocardial infarction is 50 times higher in sedentary people who suddenly start exercising compared to those who regularly exercise at a moderate or high level of exercise [17]. Hence, it is important to periodize training and adjust training loads to the body. ...
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Monitoring the training of amateur long-distance crosscountry skiers (XCS) can help ath-letes' achieve a higher exercise capacity and protect their health. The aim of this study was to assess body composition changes and lipid profiles in middle-aged amateur long-distance XCS after four months of training, including specialized roller ski training. The results of the time-to-exhaustion (TTE) test and blood tests and changes in body composition were analyzed with basic descriptive statistics: the paired Wilcoxon test was used to compare the results (initial and final). Spearman's rank correlation coefficient (R) was used to assess the influence of various variables on maximum oxygen uptake (VO2max). The findings show that training of amateur long-distance XCS improved maximal oxygen uptake (p = 0.008) and had a positive effect on fat reduction, measured in percentages (p = 0.038) and in kilograms (p = 0.023), but did not change blood lipids or other parameters. Further research could focus on other aspects of the annual training cycle: the competition period, and women in a larger group of athletes. Training with roller skis and a crosscountry skiing training machine (a specialized machine for strengthening the arms and upper body) can support health and prevent obesity, overweight, and cardiovascular disease.
... This approach can loosely divide participants into low, middle and high doses. While exercise performed at high doses is classically associated with professional athletes, there are a large number of nonprofessionals who participate in exercise to an extent that would be classified as high dose [2]. ...
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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.
... 6,7 While there is great enthusiasm among middle-aged, amateur athletes worldwide in marathon training and event participation, there are conflicting reports in the literature about beneficial or deleterious effects on the cardiovascular system with prolonged endurance exercise training. 8 Left ventricular (LV) peak global longitudinal strain (GLS), derived from speckle-tracking transthoracic echocardiography (TTE), has been demonstrated to be abnormal in amateur runners after marathon training 9,10 and may identify subclinical cardiac dysfunction. However, speckle-tracking strain echocardiography is sensitive to afterload, leading to limitations in accuracy when afterload is not factored into the analysis. ...
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Purpose: We used a novel noninvasive method based on speckle-tracking echocardiography to evaluate myocardial performance in South Asian recreational athletes who completed a half marathon. Methods: Transthoracic echocardiography was performed on 24 recreational athletes 48 hours before they took part in a half marathon (premarathon), within 2 hours of half marathon completion (postmarathon), and 72 hours after completion. Clinical, laboratory, and echocardiographic variables were collected. Speckle-tracking echocardiography was performed in all subjects to characterize myocardial mechanics. Results: Mean age of participants was 41.8 ± 7.4 years, and 23 (95.8%) were male. No subject had a prior history of coronary artery disease. Significant changes in pre- and postmarathon values suggested myocardial injury, including an increase in mean brain natriuretic peptide (BNP), an increase in left atrial volume, and an overall reduction in peak left ventricular global longitudinal strain. All subjects had a similar value of global work index, the average myocardial work, premarathon. Global work index did not change in 11 patients (Group 1), and global work index increased in 13 patients (Group 2) immediately postmarathon. Group 2 patients were noted to have higher heart rate, lower end-diastolic and end-systolic volumes, and higher BNP levels, suggesting myocardial stress. Conclusions: South Asian athletes completing a half marathon exhibited two different responses to the cardiac stress of the half marathon, as outlined by the use of myocardial work indices, a novel method for assessing cardiac performance.
... They get exposed to increased adverse health risks (i.e. musculoskeletal injuries, cardiac problems etc.) (1,5). ...
... This is known as exercise or sports paradox. The moderate to high intensity exercise, performed at regular intervals over a long period of time, has positive pleiotropic effects 42 in reducing the overall risk of atherosclerosis and acute coronary syndrome. Compared to sedentary individuals, the relative risk of SCD during 'exercise hours' is reduced by 7-10 folds and the relative risk of acute MI during 'exercise hours' is reduced by 50 folds in individuals performing regular vigorous exercise. ...
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The annual incidence of sudden cardiac death (SCD) in athletes is significantly lower than the general population. However, when SCD occurs in an athlete during sporting event or training, it sends shockwaves in the society and raises questions about cardiovascular effects of sports and exercise. This document reviews the causes and mechanism of SCD in sports and exercise in young and older athletes. In the Indian context, we suggest a 'pre-participation screening' of young and older athletes and consider a 'supervised, graded exercise regime' for the uninitiated, older sports participant. Finally, the document proposes medical infrastructure required to successfully revive a victim of sudden cardiac arrest during a sporting event.
This study proposes a simple location-based rescue request system for use in city marathons with large numbers of athletes. Instead of using passive radio frequency identification technology, the proposed system employs initiative Bluetooth low-energy communication technology. When an athlete is injured, they can immediately transmit a rescue request that contains their estimated location and the time of the injury. Upon receiving the rescue request, medical staff can respond rapidly. This study included three parts. First, the time required for a rescue team to receive a request from an injured athlete was estimated based on past international city marathon race records. Then, a software simulation was performed to extract the simplest transfer parameter requirements for system positioning. Finally, experimental samples were produced for field verification, and the rescue notification timing system was developed. This approach was found to successfully deliver 97.4%–99.9% of the athletes’ request messages within 3–4 min and maintains the error range of the rescue locations under 15 m. It is appropriate for use in city marathons owing to its simple structure, low weight, low cost, and need for only common commercial technologies that are ready for mass production.
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There is wide variability in the physical activity patterns of the patients in contemporary clinical cardiovascular practice. This review is designed to address the impact of exercise dose on key cardiovascular risk factors and on mortality. We begin by examining the body of literature that supports a dose-response relationship between exercise and cardiovascular disease risk factors, including plasma lipids, hypertension, diabetes mellitus, and obesity. We next explore the relationship between exercise dose and mortality by reviewing the relevant epidemiological literature underlying current physical activity guideline recommendations. We then expand this discussion to critically examine recent data pertaining to the impact of exercise dose at the lowest and highest ends of the spectrum. Finally, we provide a framework for how the key concepts of exercise dose can be integrated into clinical practice.
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Habitual physical activity and regular exercise training improve cardiovascular health and longevity. A physically active lifestyle is, therefore, a key aspect of primary and secondary prevention strategies. An appropriate volume and intensity are essential to maximally benefit from exercise interventions. This document summarizes available evidence on the relationship between the exercise volume and risk reductions in cardiovascular morbidity and mortality. Furthermore, the risks and benefits of moderate- versus high-intensity exercise interventions are compared. Findings are presented for the general population and cardiac patients eligible for cardiac rehabilitation. Finally, the controversy of excessive volumes of exercise in the athletic population is discussed.
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Prospective cohort studies have shown that people with a larger amount of physical activity (PA) and exercise have lower risks of non-communicable diseases (NCDs). In Japan, the Ministry of Health, Labour and Welfare published in March 2013 the "Active-Guide," i.e. the Japanese official PA guidelines for health promotion. In this document, the most important message is "+10," standing for "add 10 min of MVPA per day." The establishment of the "+10" recommendation is supported by strong scientific evidence. Firstly, a meta-analysis including 26 cohort studies indicated that an increment of 10 min of moderate-to-vigorous PA per day can result in a 3.2% reduction of the average relative risk of NCDs, dementia, joint-musculoskeletal impairment, and mortality. Secondly, the National Health and Nutrition Survey (Japan, 2010) reported that 60.8% of the Japanese population is inclined to add the equivalent of 10 min of PA in their daily life. In line with these results, the "+10" recommendation is viewed as feasible and efficient for the Japanese population. To our knowledge, this implementation of an additional low-dose PA recommendation in a governmental health promotion policy is a world first. We hope that the Japanese PA policy will inspire other national and international public health agencies.
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The role of high-intensity exercise and other emerging risk factors in lone atrial fibrillation (Ln-AF) epidemiology is still under debate. The aim of this study was to analyse the contribution of each of the emerging risk factors and the impact of physical activity dose in patients with Ln-AF. Patients with Ln-AF and age- and sex-matched healthy controls were included in a 2:1 prospective case-control study. We obtained clinical and anthropometric data transthoracic echocardiography, lifetime physical activity questionnaire, 24-h ambulatory blood pressure monitoring, Berlin questionnaire score, and, in patients at high risk for obstructive sleep apnoea (OSA) syndrome, a polysomnography. A total of 115 cases and 57 controls were enrolled. Conditional logistic regression analysis associated height [odds ratio (OR) 1.06 [1.01-1.11]], waist circumference (OR 1.06 [1.02-1.11]), OSA (OR 5.04 [1.44-17.45]), and 2000 or more hours of cumulative high-intensity endurance training to a higher AF risk. Our data indicated a U-shaped association between the extent of high-intensity training and AF risk. The risk of AF increased with an accumulated lifetime endurance sport activity ≥2000 h compared with sedentary individuals (OR 3.88 [1.55-9.73]). Nevertheless, a history of <2000 h of high-intensity training protected against AF when compared with sedentary individuals (OR 0.38 [0.12-0.98]). A history of ≥2000 h of vigorous endurance training, tall stature, abdominal obesity, and OSA are frequently encountered as risk factors in patients with Ln-AF. Fewer than 2000 total hours of high-intensity endurance training associates with reduced Ln-AF risk. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.
Background: -It is under debate whether the cumulative effects of intensive endurance exercise induce chronic cardiac damage, mainly involving the right heart. The aim of the study was to examine the cardiac structure and function in long-term elite master endurance athletes with special focus on the right ventricle by contrast enhanced cardiovascular magnetic resonance imaging (CMR). Methods and results: -Thirty-three healthy caucasian competitive elite male master endurance athletes (age range: 30 - 60 years) with a training history of 29 ± 8 years, and 33 caucasian control subjects pair-matched for age, height and weight underwent cardiopulmonary exercise testing, echocardiography including tissue-Doppler imaging and speckle tracking, and CMR. Indexed LVM and RVM (LVM/BSA: 96 ± 13 and 62 ± 10 g/m(2); P<.001; RVM/BSA: 36 ± 7 and 24 ± 5 g/m(2); P<.001) and indexed LVEDV and RVEDV (LVEDV/BSA 104 ± 13 and 69 ± 18 ml/m(2); P<.001; RVEDV/BSA 110 ± 22 and 66 ± 16 ml/m(2); P<.001) were significantly increased in athletes (A) compared to control subjects (C). RVEF did not differ between A and C (52 ± 8 and 54 ± 6 %; P=.26). Pathological late enhancement was detected in one athlete. No correlations were found for LV and RV volumes and EF with NT pro-BNP, and high sensitive Troponin was negative in all subjects. Conclusions: -Based on our results, a chronic RV damage in elite endurance master athletes with lifelong high training volumes seems to be unlikely. Thus, the hypothesis of an exercise-induced ARVC has to be questioned.