ArticleLiterature Review

Premarathon Evaluations: Is There a Role for Runner Prerace Medical Screening and Education to Reduce the Risk of Medical Complications?

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There is irrefutable evidence that regular participation in physical activity has substantial health benefits, and as such participation in mass community-based sports events should be supported. However, with the promotion of physical activity comes the potential risk of medical complications during an acute exercise session, with this risk varying according to the risk factor profile of an individual and the nature of the event. The demographics of marathon race entrants changed over the past two to three decades, and currently about 50% of runners are older than 40 yr. A consolidated view of previously published research shows that in a marathon with a field of 50,000 runners for example, the medical staff will, on average, encounter a sudden death every 2 to 3 yr, a sudden cardiac arrest every year, 25 runners that present with a serious medical complication requiring specialized management or hospitalization, and 1000 runners that require medical attention. Runners may have several intrinsic risk factors that can predispose them to serious acute cardiovascular or other serious noncardiac medical complications on race day. This intrinsic risk can be exacerbated by several ex-trinsic risk factors as well. As health care professionals, we are obliged to give the best medical advice to individuals who wish to participate in moderate-and high-intensity endurance activities, and at the same time reduce their risk of a medical complication during exercise. Preliminary data indicate that an online prerace medical screening and targeted educational intervention program can be successfully implemented and is effective in reducing the risk of acute medical complications during a race.
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... There is a growing awareness of the irrefutable and considerable health benefits associated with regular exercise. Moreover, there is an increase in the participation in mass community-based endurance sporting events, in particular marathon running [1,2], where increased participation is especially popular among older runners and female runners [2,3]. However, prolonged moderate-to high-intensity exercises such as distance running also transiently increases the risk for moderate and serious medical encounters in a variety of organ systems [4][5][6][7][8]. ...
... The incidence of and risk factors associated with these medical encounters at distance running events have been reported [11][12][13][14]. The use of chronic prescription medication (CPM) is part of several international pre-participation screening questionnaires to identify individuals at higher risk of medical complications during exercise [15][16][17] and has been identified as a potential risk factor for developing medical encounters during long-distance running races [1,18]. CPM use during exercise may increase the risk of cardiovascular complications, severe fluid and electrolyte abnormalities, acute renal failure, rhabdomyolysis, exertional heat stroke, gastrointestinal bleeding, and tendon injuries [18]. ...
... The main elements of the online medical screening questionnaire have previously been described [2]. In summary, the questionnaire consisted of demographic questions (including age, sex, and race distance), training-related questions and questions related to factors that are associated with a possible increased risk of adverse medical events in moderate-to high-intensity exercises such as distance running [1]. These included: symptoms of cardiovascular disease (CVD); risk factors for CVD; history of diagnosed specific chronic diseases; history of prescribed medication used to treat chronic medical conditions or injuries; medication use during racing; history of running injuries; and history of EAMC. ...
Article
Background: Exercise associated collapse (EAC) is a common medical encounter at distance running events. Risk factors associated with EAC are not well documented. The objective is to determine the overall incidence of EAC and identify risk factors associated with EAC in 21.1km and 56km runners. Methods: A cross-sectional analysis of 153208 race starters from the Two Oceans Marathon races (2008-2015). All EACs on race day were documented by medical staff. Risk factors associated with EAC investigated included demographics, race distance (21.1km vs. 56km), running speed, race experience and race day environmental data (wet-bulb globe temperature [WBGT], humidity, wind speed). Incidence (per 1000 starters; 95%CIs) and incidence ratios (95%CIs) were calculated. Results: The overall incidence of EAC was 1.50 (95% CI 1.31-1.71). Longer race distance (IR: 2.1; 1.6-2.7; p<0.0001) and slower running speed (IR: 1.3; 1.1-1.5; p=0.0017) were significant risk factors associated with EAC. The incidence of EAC was higher in female vs. male 21.1km race starters (IR=2.25; 1.47-3.46; p=0.0229). Age and environmental conditions were not associated with EAC (p>0.05) in a cool and temperate environment. Conclusions: About 1 in 667 race starters (21.1km and 56km) develop EAC. Longer race distance, slower running speed and female sex (in 21.1km starters) are significant risk factors associated with EAC. Race medical directors can identify race entrants that may be at risk of developing EAC, develop prevention strategies and better prepare medical care at these events.
... Distance running is increasing in popularity all over the world [4] and 35% of all marathon participants in 2019 were older than 45 years old [5]. Older participants are at higher risk for acute medical complications during moderate to intense exercise as per the exercise benefit-risk paradox [6,7]. Also, previous studies have highlighted the increased risk of medical complications during exercise related to the advancing age of participants [2,8,9]. ...
... Acute serious cardiac events such as myocardial infarction, arrhythmia and sudden cardiac arrest are well described in both younger and older athletes during sports events [12][13][14]. Leading organizations recommend various pre-exercise screening regimes to identify those at risk, especially in masters (>50 years) athletes [6,15,16] using detailed and comprehensive pre-exercise screening questionnaires, in the form of a 'self-assessment of risk.' The benefits of these screening questionnaires and subsequent interventions to reduce the risk of adverse events have been studied and advocated [6,17]. ...
... Leading organizations recommend various pre-exercise screening regimes to identify those at risk, especially in masters (>50 years) athletes [6,15,16] using detailed and comprehensive pre-exercise screening questionnaires, in the form of a 'self-assessment of risk.' The benefits of these screening questionnaires and subsequent interventions to reduce the risk of adverse events have been studied and advocated [6,17]. Despite this, most endurance sports events either do not perform pre-race screening or only use a limited voluntary declaration of medical conditions and/or allergies as part of the race entry process. ...
Article
Objectives To determine the prevalence of self-reported pre-race chronic medical conditions and allergies in ultramarathon race entrants and to explore if these are associated with an increased risk of race-day medical encounters (MEs). Methods Data from two voluntary open-ended pre-race medical screening questions (Q1 – history of allergies; Q2 - history of chronic medical conditions/prescription medication use) were collected in 133 641 Comrades Marathon race entrants (2014-2019). Race-day ME data collected prospectively over 6 years are reported as incidence (per 1000 starters) and incidence ratios (IR: 95%CI’s). Results : Pre-race medical screening questions identified race entrants with a history of chronic medical conditions and/or prescription medication use (6.9%) and allergies (7.4%). The % entrants with risk factors for cardiovascular disease (CVD) was 30% and being older (>45years) and male (27.5%) were the most frequent CVD risk factors. 0.3% of entrants reported existing CVD. The overall incidence of MEs was 20/1000 race starters. MEs were significantly higher in race entrants reporting a “yes” to Q1 (allergies) (IR=1.3; 1.1-1.5) (p=0.014) or Q2 (chronic medical conditions and/or prescription medication use) (IR=1.3; 1.1-1.5) (p=0.0006). Conclusions Voluntary completion of two open-ended questions identified chronic medical conditions and/or prescription medication use in 6.9% and allergies in 7.4% of ultramarathon race entrants. This is lower than that reported for other races that implemented compulsory completion of a more comprehensive pre-screening questionnaire. Despite potential under-reporting, a pre-race self-reported history of chronic medical conditions and allergies was associated with a higher risk of race-day MEs.
... There is a growing awareness of the irrefutable and considerable health benefits associated with regular exercise. Moreover, there is an increase in the participation in mass community-based endurance sporting events, in particular marathon running [1,2], where increased participation is especially popular among older runners and female runners [2,3]. However, prolonged moderate-to high-intensity exercises such as distance running also transiently increases the risk for moderate and serious medical encounters in a variety of organ systems [4][5][6][7][8]. ...
... The incidence of and risk factors associated with these medical encounters at distance running events have been reported [11][12][13][14]. The use of chronic prescription medication (CPM) is part of several international pre-participation screening questionnaires to identify individuals at higher risk of medical complications during exercise [15][16][17] and has been identified as a potential risk factor for developing medical encounters during long-distance running races [1,18]. CPM use during exercise may increase the risk of cardiovascular complications, severe fluid and electrolyte abnormalities, acute renal failure, rhabdomyolysis, exertional heat stroke, gastrointestinal bleeding, and tendon injuries [18]. ...
... The main elements of the online medical screening questionnaire have previously been described [2]. In summary, the questionnaire consisted of demographic questions (including age, sex, and race distance), training-related questions and questions related to factors that are associated with a possible increased risk of adverse medical events in moderate-to high-intensity exercises such as distance running [1]. These included: symptoms of cardiovascular disease (CVD); risk factors for CVD; history of diagnosed specific chronic diseases; history of prescribed medication used to treat chronic medical conditions or injuries; medication use during racing; history of running injuries; and history of EAMC. ...
Article
Objective To determine the prevalence of chronic prescription medication (CPM) use in distance runners (by age and sex) and to compare CPM use in 21.1km vs. 56km race entrants. Methods A cross-sectional study of 76654 race entrants who completed a pre-race medical screening questionnaire during race registration, which included questions on the use of CPM and CPM use in eight main categories of CPM. Prevalence (%, 95%CIs) and prevalence ratios (PR) are reported. Results The prevalence of any CPM use was 12.5% (12.2-12.8). CPM use was higher in older age categories vs. the youngest age category (31-40yrs vs. ≤30yrs: PR=1.4; 41-50yrs vs. ≤30yrs: PR=2.1; >50yrs vs. ≤30yrs: PR=3.4) (p<0.0001) and females vs. males (PR=1.1; p<0.0001). The use of any CPM was significantly higher in 21.1km vs. 56km race entrants (PR=1.2; p<0.0001). Prevalence of CPM use in main categories were: blood pressure lowering medication (3.7%), cholesterol lowering medication (3.6%), asthma medication (3.1%), and medication to treat anxiety/depression (2.6%). The pattern of CPM in the main categories differed between 21.1km and 56km race entrants. Conclusions 1 in 8 race entrants use CPM, with a higher prevalence of use among older race entrants, female vs. males, and 21.1km vs. 56km race entrants. Frequent CPM used are blood pressure lowering medication, cholesterol lowering medication, asthma medication, and medication to treat anxiety/depression. Use of CPM medications may increase the risk of medical complications during exercise and these data help identify subgroups of entrants that may be at higher risk for race medical encounters.
... 8,11 The incidence rate (IR) (per 100 000 race starters) of sudden death during/after distance running events is 0.4-3.4, 12 with the IR of sudden cardiac arrest at least double (2.18). 11 The IR of serious life-threatening MEs (16.7-155 per 100 000), 8,12 and all MEs (827-4449 per 100 000), 8,12 are considerably higher. ...
... 12 with the IR of sudden cardiac arrest at least double (2.18). 11 The IR of serious life-threatening MEs (16.7-155 per 100 000), 8,12 and all MEs (827-4449 per 100 000), 8,12 are considerably higher. These data show that documenting only sudden cardiac arrests or deaths during sporting events and represent only the "tip of the iceberg" of the total medical burden during/after a mass community-based sports event. ...
... 12 with the IR of sudden cardiac arrest at least double (2.18). 11 The IR of serious life-threatening MEs (16.7-155 per 100 000), 8,12 and all MEs (827-4449 per 100 000), 8,12 are considerably higher. These data show that documenting only sudden cardiac arrests or deaths during sporting events and represent only the "tip of the iceberg" of the total medical burden during/after a mass community-based sports event. ...
Article
Full-text available
Background: Pre-race screening and risk stratification in recreational endurance runners may predict adverse events (AEs) during a race. Aim: To determine if pre-race screening and risk stratification predicts AEs during a race. Methods: 29585 participants (Male 71.1%, average age=42.1years; Female 28.9%, average age=40.2years) at the Two Oceans ultra-marathon races (56km) completed a pre-race medical screening questionnaire, and were risk stratified into four pre-specified groups [very high risk (VHR; existing cardiovascular disease-CVD:3.2%), high risk (HR; risk factors for CVD:10.5%), intermediate risk (IR; existing other chronic disease, medication use or injury:53.3%), and low risk (LR:33.0%)]. Race starters, finishers, and medical encounters (ME) were recorded. Did-not-start (DNS) rate (per1000 entrants that did-not-start), did-not-finish (DNF) rate (per1000 starters that did-not-finish), AE rate [per1000 starters that either DNF or had an ME] and ME rate (per1000 starters with an ME) were compared across risk categories. Results: AEs were significantly higher (per1000 starters; 95%CI) in the VHR (68.9; 52.4-89.9:p=0.0407) compared to the LR (51.3; 46.5-56.7). The DNS rate was significantly different between the IR (190.3; 184.0-196.9) and LR (207.4; 199.2-216.0:p=0.0011). DNF rates were not different in the VHR (56.4; 41.9-75.9) compared to LR (44.2; 39.7-49.1:p=0.1295) and ME rate was also not different between risk categories, however VHR (12.9; 7.0-23.9) was approaching significance compared to LR (6.9; 5.2-9.1:p=0.0662). Conclusion: Pre-race medical screening and risk stratification may identify athletes at higher risk of AEs. Further studies should be performed in larger cohorts to clarify the role of pre-race medical screening in reducing AEs in endurance runners.
... Other heart issues revolve around changes in cardiac structure thought to increase atrial fibrillation or a-fib (Lavie et al., 2015), and elevate troponin levels (Predel, 2014). Age again is mentioned as a risk factor which cannot be separated from the accumulation of lifestyle habits, often not ideal prior to acquiring the lifestyle of a marathon runner (Pressler et al., 2017;Schwellnus, 2017). ...
... This statistic is not limited to repeated overuse of joint-specific pains. Long-distance running creates undue physiological stress resulting in cardiac issues (O'Keefe et al., 2012;Schwellnus, 2017). An explanation was necessary to understand what motivates these runners to adhere to marathon running despite the recognized impact of physical adversities creating risk. ...
... Several non-modifiable risk factors measure the status of cardiovascular health. Several of these include gender, age, and chronic disease which is not limited only to the known but the unknown, the presence of CVD risk factors before to such diagnosis, and the symptoms (Schwellnus, 2017). As risk factors can change, they should be discussed with a health care provider before beginning any fitness program. ...
Research
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Abstract: Despite the high occurrence of running-related injuries, master level runners, those aged 40 years and older, account for 50% of all marathon finishers. What is not known is the common motive sustaining participation, especially among this age demographic. The self-determination theory was the theoretical framework to support how behavior is regulated by the individual. The purpose of this quantitative research was to identify a difference in the motives (psychological, physical, social, and achievement) and their subcategorical motives (health orientation, weight concern, affiliation, recognition, psychological coping, life meaning, self-esteem, competition, and personal goals) via the Motivations of Marathoners Scales by master level runners according to their injury status and gender. Two hundred and twenty-five master level runners from social media marathon running groups completed the online survey. The responses were analyzed using an independent-samples t test and an ANOVA. The results showed female master level runners statistically significant in psychological coping, life meaning, self-esteem, health orientation, weight concern, and affiliation which contributed to psychological, physical, and social motives while male master level runners were statistically significant only in the subcategory of competition. The implications for positive social change include a better understanding of motivation, its sustainment, and the adherence of physical activity behaviors to improve the positive influence among the current beliefs about aging and activity for better health of individuals and their communities.
... While the health benefits of exercise are numerous, medical complications during moderate-to high-intensity vigorous physical activity, such as distance running, in a variety of organ systems have been described [4-6] Acute cardiac events, including myocardial infarction and sudden death, are described in both younger and older runners [7-10]. Determining the risk of sudden death during exercise, in particular during distance running events such as the halfmarathon (21.1 km) and marathon (42.2 km) [11,12] using pre-screening tests and detailed diagnostics (ECG) has been proposed [5][6][7][8][13][14][15][16]. ...
... Furthermore, we wanted to determine the factors in the current guidelines that trigger this recommendation. As a secondary aim, we also explore the prevalence of other potential "risk factors" associated with serious non-cardiac medical complications such as other chronic systemic diseases, use of medication, and previous collapse during exercise [6] that are not currently routinely included in international pre-exercise screening guidelines. ...
... age groups (Table 1). Online pre-race medical screening questionnaire An online pre-race medical screening questionnaire (OPRMSQ) or "self-assessment of risk" was developed to identify runners that are at possible increased risk of acute medical complications during moderate-to high intensity exercise such as a distance running race [6]. The questions were based on the ESC and the EACPR guidelines for pre-exercise screening [28] with additional questions on general prescription medication use, including medication use during racing and a past history of collapse during racing. ...
Article
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 56km) in South Africa (n=15778) 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 4941 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.
... 1,[4][5][6][7] Not surprisingly, in the past 2 to 3 decades, participation in mass community-based endurance sports events (running, cycling, swimming, and triathlons) has seen a steady growth worldwide 8 with notable increases in older participants. 9 Recreational distance running remains one of the most popular forms of endurance exercise, and since 1976, there is a reported increase of .12-fold in overall participation numbers in distance races such as the marathon (http://www.runningusa.org/annual-reportsaccessed on February 1, 2018). ...
... 10,11 These complications include serious cardiac incidents [12][13][14][15][16] and noncardiac complications typically related to severe fluid and electrolyte abnormalities (mainly hyponatremia), [17][18][19] acute kidney injury and renal failure, 20-23 exertional heat stroke, [24][25][26][27][28] and gastrointestinal (GIT) bleeding. 29 Risk factors associated with acute medical complications (cardiac and noncardiac) were recently reviewed, 9 and one of the risk factors is the use of medication, immediately before or during races. 9 The most common type of medication used by athletes is prescription and over-the-counter (OTC) analgesic and/or anti-inflammatory medication (AAIM). ...
... 29 Risk factors associated with acute medical complications (cardiac and noncardiac) were recently reviewed, 9 and one of the risk factors is the use of medication, immediately before or during races. 9 The most common type of medication used by athletes is prescription and over-the-counter (OTC) analgesic and/or anti-inflammatory medication (AAIM). 30 Analgesic/antiinflammatory medication use during training, competition, and recovery is common practice in many athletes including Olympic athletes, 31,32 Paralympic athletes, 33 elite track and field athletes, 34 football (soccer) players, [35][36][37][38] athletes participating in multicoded sports events, 39 college athletes, 40 athletes participating in triathlon, 41,42 and endurance cycling. ...
Article
Objective: Analgesic/anti-inflammatory medication (AAIM) increases the risk of medical complications during endurance races. We determined how many runners use AAIM before or during races, AAIM types, and factors associated with AAIM use. Design: Cross-sectional study. Setting: 21.1-km and 56-km races. Participants: Seventy-six thousand six hundred fifty-four race entrants. Methods: Participants completed pre-race medical screening questions on AAIM use, running injury or exercise-associated muscle cramping (EAMC) history, and general medical history. Main outcome measures: Analgesic/anti-inflammatory medication use, types of AAIM (% runners; 95% confidence interval), and factors associated with AAIM use (sex, age, race distance, history of running injury or EAMC, and history of chronic diseases) [prevalence ratio (PR)]. Results: Overall, 12.2% (12.0-12.5) runners used AAIM 1 week before and/or during races (56 km = 18.6%; 18.0-19.1, 21.1 km = 8.3%; 8.1-8.6) (P < 0.0001). During races, nonsteroidal anti-inflammatory drugs (NSAIDs) (5.3%; 5.1-5.5) and paracetamol (2.6%; 2.4-2.7) were used mostly. Independent factors (adjusted PR for sex, age, and race distance; P < 0.0001) associated with AAIM use were running injury (2.7; 2.6-2.9), EAMC (2.0; 1.9-2.1), cardiovascular disease (CVD) symptoms (2.1; 1.8-2.4), known CVD (1.7; 1.5-1.9), CVD risk factors (1.6; 1.5-1.6), allergies (1.6; 1.5-1.7), cancer (1.3; 1.1-1.5), and respiratory (1.7; 1.6-1.8), gastrointestinal (2.0; 1.9-2.2), nervous system (1.9; 1.7-2.1), kidney/bladder (1.8; 1.6-2.0), endocrine (1.5; 1.4-1.7), and hematological/immune (1.5; 1.2-1.8) diseases. Conclusions: 12.2% runners use AAIM before and/or during races, mostly NSAIDs. Factors (independent of sex, age, and race distance) associated with AAIM use were history of injuries, EAMC, and numerous chronic diseases. We suggest a pre-race screening and educational program to reduce AAIM use in endurance athletes to promote safer races.
... 32 However, SD and cardiac arrest represent only the 'tip of the iceberg' of medical encounters at mass community-based endurance sports events. 33 The incidence of a serious life-threatening medical encounter (eg, myocardial infarction, exertional heat stroke, hyponatraemia) at a distance running event, such as the marathon, varies between 16.7 and 155 per 100 000 race entrants, 8 33 and this is 50-100 times higher than the incidence of SD. 33 To date, non-fatal but serious medical encounters have not been well characterised across the majority of endurance events, and there is no current consensus on the definition of a 'serious life-threatening' medical encounter on race day. The absence of a uniform definition for serious life-threatening and somewhat less serious medical encounters makes it difficult to compare incidence and prevalence between events. ...
... 32 However, SD and cardiac arrest represent only the 'tip of the iceberg' of medical encounters at mass community-based endurance sports events. 33 The incidence of a serious life-threatening medical encounter (eg, myocardial infarction, exertional heat stroke, hyponatraemia) at a distance running event, such as the marathon, varies between 16.7 and 155 per 100 000 race entrants, 8 33 and this is 50-100 times higher than the incidence of SD. 33 To date, non-fatal but serious medical encounters have not been well characterised across the majority of endurance events, and there is no current consensus on the definition of a 'serious life-threatening' medical encounter on race day. The absence of a uniform definition for serious life-threatening and somewhat less serious medical encounters makes it difficult to compare incidence and prevalence between events. ...
Article
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.
... The study suggests that online prerace medical screening and targeted educational interventions can significantly reduce the risk of acute medical complications during a race. 26 The understanding of the present data obtained collectively emphasize the necessity of periodic health checkups for marathon runners to ensure their safety and overall health. ...
Article
Full-text available
Background: The purpose of this study was to investigate the prevalence of chronic medical conditions and healthcare utilization among Indian marathon athletes through a digital survey. Methods: This was a cross-sectional, observational study that employed a questionnaire-based digital survey of Indian marathon athletes. The survey collected data on participants' demographics, training history, chronic medical conditions, and healthcare utilization. Descriptive statistics were used to analyze the data. Results: A total of 224 marathon athletes participated in the survey from April 2023 to June 2023. The largest segment of respondents (40.6%) fell within the age bracket of over 50 years, and 82.3% were male. Among the participants, 84.9% were married, and 77% were employed in the private sector. About 56% were involved in some sports activity prior and 90% opined they follow a healthy lifestyle. On comorbidities, hypertension was most prevalent (23.2%) followed by diabetes (13%), hyperlipidemia (9.3%), and asthma (2.2%). About 95% do not take any pain medications during a marathon and 29 % were not aware of the precautions to be taken for running a marathon with chronic medical conditions. Around 69.6% do not consult a physician to get advice and approval before a marathon and 73.1% mentioned that they do not take regular medication for chronic medical conditions like diabetes and hypertension Conclusion: Indian marathon athletes have a significant prevalence of chronic medical conditions, with hypertension, asthma, and diabetes being the most common. A substantial proportion of athletes sustain injuries during training and competition, leading to healthcare utilization, particularly for physical therapy. These findings highlight the importance of comprehensive pre-participation medical evaluations and targeted injury prevention strategies for this population.
... While the health benefits of physical activity are numerous, the increased risk of musculoskeletal injury, acute cardiac episodes, and medical complications cannot be overlooked [67,68]. This risk is significantly higher in older individuals and those with established cardiovascular disease risk factors or diagnosed disease. ...
Article
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Background: In low-to-middle income countries (LMICs), there is a growing burden of non-communicable diseases (NCDs) placing strain on the facilities and human resources of healthcare systems. Prevention strategies that include lifestyle behavior counseling have become increasingly important. We propose a potential solution to the growing burden of NCDs through an expansion of the role for community health workers (CHWs) in prescribing and promoting physical activity in public health settings. This discussion paper provides a theoretical model for task-shifting of assessment, screening, counseling, and prescription of physical activity to CHWs. Five proposed tasks are presented within a larger model of service delivery and provide a platform for a structured, standardized, physical activity prevention strategy aimed at NCDs using CHWs as an integral part of reducing the burden of NCDs in LMICs. However, for effective implementation as part of national NCD plans, it is essential that CHWs received standardized, ongoing training and supervision on physical activity and other lifestyle behaviors to optimally impact community health in low resource settings.
... hyponatraemia. 6 Individuals at higher risk of MEs should be identified and are usually older male athletes with underlying cardiovascular disease 2,6-8 and other chronic diseases. 9,10 In most mass community-based endurance sports events, male entrants still predominate and over the past 2-3 decades the number of older participants has increased. ...
Article
Full-text available
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.
... Prior to the majority of runners reaching the middle-and later-distance checkpoints, resources and medical staff should be moved from the early tents to the later first-aid stations [149]. Further, pre-marathon evaluations and education might be beneficial to reduce medical complications [151]. ...
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Exercise-associated hyponatremia (EAH) was first described as water intoxication by Noakes et al. in 1985 and has become an important topic linked to several pathological conditions. However, despite progressive research, neurological disorders and even deaths due to hyponatremic encephalopathy continue to occur. Therefore, and due to the growing popularity of exercise-associated hyponatremia, this topic is of great importance for marathon runners and all professionals involved in runners’ training (e.g., coaches, medical staff, nutritionists, and trainers). The present narrative review sought to evaluate the prevalence of EAH among marathon runners and to identify associated etiological and risk factors. Furthermore, the aim was to derive preventive and therapeutic action plans for marathon runners based on current evidence. The search was conducted on PubMed, Scopus and Google Scholar using a predefined search algorithm by aggregating multiple terms (marathon run; exercise; sport; EAH; electrolyte disorder; fluid balance; dehydration; sodium concentration; hyponatremia). By this criterion, 135 articles were considered for the present study. Our results revealed that a complex interaction of different factors could cause EAH, which can be differentiated into event-related (high temperatures) and person-related (female sex) risk factors. There is variation in the reported prevalence of EAH, and two major studies indicated an incidence ranging from 7 to 15% for symptomatic and asymptomatic EAH. Athletes and coaches must be aware of EAH and its related problems and take appropriate measures for both training and competition. Coaches need to educate their athletes about the early symptoms of EAH to intervene at the earliest possible stage. In addition, individual hydration strategies need to be developed for the daily training routine, ideally in regard to sweat rate and salt losses via sweat. Future studies need to investigate the correlation between the risk factors of EAH and specific subgroups of marathon runners.
... 25 Pre-race screening instruments, such as the ePAR-Q+, 26 have also been developed and have showed promising preventive results. 27 These interventions have focused on prevention of catastrophic illness episodes, and not on maintaining recreational runners' race performance. The results of this study indicate that recreational runners having had their build-up to the race disturbed by illness would benefit from consulting a medical professional pre-race. ...
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Objectives: To investigate health-related factors associated with self-rated race performance outcomes among recreational long-distance runners. Design: Panel study. Methods: Data were collected from runners one month before and after a community-level race event including distances from 8 to 42.2 km. The primary outcome measure was self-rated race performance outcome. The explanatory variables represented health complaints suffered during the build-up year, the pre-race month, and the race and among full marathon runners predicted objective performance outcome (mean pace equal to training pace or faster). Multiple logistic regression was used to determine factors associated with the self-rated performance outcome. Results: Two-hundred forty-five runners (29%) provided complete data sets. Seventy-four percent of the runners reached their desired race performance outcome. Achievement of the performance outcome was more likely when having avoided illness during the build-up and pre-race periods (OR = 3.8; 95% CI:1.8-8.0, p < 0.001), having avoided per-race injury (OR=3.0; 95% CI:1.2-7.4, p = 0.02) and avoided per-race illness (OR = 4.1; 95% CI:1.3-15, p = 0.020). Having obtained the self-rated performance outcome was also associated with running a shorter distance (OR=3.6; 95% CI: 1.7-8.0, p = 0.001) and being younger than 50 years of age (OR = 2.4; 95% CI:1.1-5.3-8.3, p = 0.03). Having met the predicted objective performance outcome predisposed marathon runners to also obtain the self-rated performance outcome (OR = 4.7, 95% CI: 1.5-16, p < 0.01). Conclusions: Having avoided illness during build-up and pre-race was positively associated with self-rated race performance outcome among recreational runners. Adjusting the desired performance outcomes with regard to recent illness and age may help recreational runners to more often achieve their goals and thereby prevent them from leaving the sport.
... The mean speed of runners who went to cardiac arrest was 10 We did not examine the risk of cardiac arrest and the reduction factors in our study, there are several studies indicating the importance of screening prior to the race and the efficiency of taking prophylactic Aspirin [10] [11]. Cardiac arrest could be occurred in marathon even with adequate prevention, so creating the medical support systems is needed to handle sudden cardiac arrest rapidly. ...
Article
Objective To determine if any gradual onset running-related injury (GORRI) was associated with any allergies, multiple allergies (allergies to animals, plants, medication), and allergy medication use. Design Cross-sectional descriptive study. Setting Two Oceans Marathons (56 km, 21.1 km), South Africa. Participants A total of 76 654 race entrants (2012–2015). Independent Variables The prevalence (%) and prevalence ratios (PR; 95% confidence intervals) for history of (1) any allergies, (2) multiple allergies to broad categories of allergens (animal material, plant material, allergies to medication, and other allergies), and (3) allergy medication use. Main Outcome Measures Using a compulsory online screening questionnaire, the outcome was a history of any GORRIs, and subcategories of GORRIs (muscle, tendon) in the past 12 months and history of GORRIs (and subtypes of GORRIs) were reported. Results In 68 258 records with injury and allergy data, the following were significantly associated with reporting any GORRIs: a history of any allergy (PR = 2.2; P < 0.0001), a history of allergies to broad categories of allergens (animal, plant, medication allergy, other) ( P < 0.0001), and the use of allergy medication ( P < 0.0001). A history of any allergies (PR = 2.4; P < 0.0001), all broad categories of allergies, and allergy medication use were significantly associated with muscle ( P < 0.0001) and tendon injuries ( P < 0.0001). The risk of reporting a GORRI increased as the number of reported categories of allergies increased ( P < 0.0001). Conclusions A novel finding was the cumulative risk effect with a history of multiple allergies. Further studies should aim to determine the underlying mechanism relating allergies and GORRIs.
Chapter
Periodic health evaluations (PHE) are used to medically screen athletes for participation in sporting events. In its basic form, the PHE is an opportunity to determine the current health of an athlete and develop a relationship between the athlete and their medical team. However, the scope of PHEs have evolved, and these encounters are now also used to create robust profiles for injury and illness prevention, return to play, and performance optimization programs. This chapter introduces a systems approach to the PHE, with special considerations for the PHE of endurance athletes.KeywordsPreventive medicinePeriodic health evaluationPre-participation examinationScreeningInjury prevention
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Background: Healthy lifestyle habits more to combat the sedentary lifestyle, results in the increase in the practice of physical activity (PA) in the current population. In the past 10 years, sports racing achieved its greatest exponent; meanwhile, there is a lack of cardiovascular monitoring by the participants. The aim of this study is to know the perception of the importance of cardiovascular risk control during workouts and popular races.
Chapter
Physical inactivity is one of the major modifiable risk factors for non-communicable diseases (NCDs) and universal prescription guidelines for physical activity for all individuals include engaging in >150 min of moderate- to high intensity physical exercise weekly. Participation in mass community-based sporting events including park runs, road races (distances vary from 5 km to ultra-marathons), cycling events, swimming events, and events combining endurance sports e.g. triathlon is increasing, and the profile of participants at these events is also changing, with increasing numbers of older individuals and female participants. There is a known risk of medical complications during moderate- to high intensity exercise, and this risk varies according to the “risk profile” of the individual. These medical complications during exercise can vary from minor to severe life-threatening and also result in death from cardiac arrest and other causes. Medical staff, that are responsible for participant safety at mass community-based sporting events, need to be aware of the risk of medical encounters at events, causes and risk factors associated with medical encounters, and can design and implement strategies to reduce the risk of medical encounters at these events. In this Chapter we review the risk, definition and classification of medical encounters at mass community-based sports events, highlight the exercise benefit-risk paradox, and outline a step-wise plan to reduce the risk of medical encounters at mass community-based sports events. We explore the potential role of pre-event medical screening for mass sporting events and formulate a plan to implement medical care on race day for mass community-based sporting events. Finally, we present guidelines to minimize the potential negative effects of environmental stress, including air quality at mass community-based sporting events.
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Exercise is universally recognized for its health benefits and distance running has long been a popular form of exercise and sport. Ultramarathons, defined as races longer than a marathon, have become increasingly popular in recent years. The diverse ultramarathon distances and courses provide additional challenges in race performance and medical coverage for these events. As the sport grows in popularity, more literature has become available regarding ultramarathon-specific illnesses and injuries, nutrition guidelines, psychology, physiologic changes, and equipment. This review focuses on recent findings and trends in ultramarathon running.
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Objectives To examine the efficacy and feasibility of an online prerace medical screening and educational intervention programme for reducing medical complications in long-distance races. Methods This was an 8-year observational study of medical encounter rates among 153 208 Two Oceans race starters (21.1 and 56 km) in South Africa. After the first 4-year control (CON) period, we introduced an online prerace medical screening (based on European pre-exercise screening guidelines) and an automated educational intervention programme. We compared the incidence of medical encounters (per 1000 starters; all and serious life threatening) in the CON versus the 4-year intervention (INT) period. Results In comparison to the CON period (2008–2011: 65 865 starters), the INT period (2012–2015: 87 343 starters) had a significantly lower incidence (adjusted for age group, sex, race distance) of all medical encounters by 29% (CON=8.6 (7.9–9.4); INT=6.1 (5.6–6.7), p<0.0001), in the 21.1 km race by 19% (CON=5.1 (4.4–5.9); INT=4.1 (3.6–4.8), p=0.0356) and in the 56 km race by 39% (CON=14.6 (13.1–16.3); INT=9.0 (7.9–10.1), p<0.0001). Serious life-threatening encounters were significantly reduced by 64% (CON=0.6 (0.5–0.9); INT=0.2 (0.1–0.4); p=0.0003) (adjusted for age group and sex). Registration numbers increased in the INT period (CON=81 345; INT=106 743) and overall % race starters were similar in the CON versus INT period. Wet-bulb globe temperature was similar in the CON and INT periods. Conclusion All medical encounters and serious life-threatening encounters were significantly lower after the introduction of a prescreening and educational intervention programme, and the programme was feasible.
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Aim: There are limited data on the negative effects of exercise in athletes with acute infective illness. The aim of this study was to determine whether a recently diagnosed prerace acute illness in runners affects the ability to finish a race. Methods: Runners were prospectively evaluated in the 3 days before the race for acute infective illness and then received participation advice using clinical criteria based on systemic or localised symptoms/signs. We compared the did-not-start and the did-not-finish frequencies of ill runners (Ill=172: localised=58.7%; systemic=41.3%) with that of a control group of runners (Con=53 734). Results: Runners with a systemic illness were 10.4% more likely not to start compared with controls (29.6% vs 19.2%) (p=0.0073). The risk difference of not starting the race in runners who were advised not to run the race compared with controls was 37.3% (56.5% vs 19.2%, p<0.0001). Compared with controls, runners with illness had a significantly (p<0.05) greater risk (any illness (5.2% vs 1.6%), systemic illness (8.0% vs 1.6%), illness <24 hours before the race (11.1% vs 1.6%)) and relative risk (prevalence risk ratio) (any illness=3.4, systemic illness=4.9, systemic illness <24 hours before the race=7.0) of not finishing the race. Conclusions: Runners with prerace acute systemic illness, and particularly those diagnosed <24 hours before race day, are less likely to finish the race, indicating a reduction in race performance.
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Background Masters athletes (MAs), people over the age of 35 that participate in competitive sports, are a rapidly growing population that may be uniquely at risk for cardiovascular (CV) disease. The objective of this study was to develop a comprehensive clinical CV profile of MA. Methods An electronic Internet-based survey (survey response rate = 66 %) was used to characterize a community cohort of MAs residing in Eastern Massachusetts, USA. Clinical and lifestyle factors associated with prevalent CV disease were determined using logistic regression. ResultsAmong 591 MAs (66 % men, age = 50 ± 9 years) with 21.3 ± 5.5 years of competitive endurance sport exposure, at least one CV risk factor was present in 64 % including the following: family history of premature atherosclerosis (32 %), prior/current tobacco exposure (23 %), hypertension (12.0 %), and dyslipidemia (7.4 %). There was a 9 % (54/591) prevalence of established CV disease which was accounted for largely by atrial fibrillation (AF) and coronary atherosclerosis (CAD). Prevalent AF was associated with years of exercise exposure [adjusted odds ratio, OR (95 % confidence intervals); OR = 1.10 (1.06, 1.21)] and hypertension [OR = 1.05 (1.01, 1.10)] while CAD was associated with dyslipidemia [OR = 9.09 (2.40, 34.39)] and tobacco use [OR = 1.78 (1.34, 3.10)] but was independent of exercise exposure. Conclusions Among MAs, AF is associated with prior exercise exposure whereas CAD is associated with typical risk factors including dyslipidemia and prior tobacco use. These findings suggest that there are numerous opportunities to improve disease prevention and clinical care in this population.
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Cardiovascular (CV) screening in young athletes remains challenging and a topic of considerable debate. Recent criticisms of ECG screening have perpetuated arguments that ECG screening is neither indicated nor effective by applying outdated incidence data and flawed methodology. In response, this article provides a critical review of the arguments in favour of ECG screening in athletes and the early detection of CV disorders at elevated risk of sudden cardiac death (SCD). Importantly, no study to date has demonstrated that screening by history and physical examination alone is effective in detecting athletes at risk or in preventing SCD. ECG screening using current athlete-specific interpretation standards provides a low false-positive rate and improves detection of potentially lethal CV conditions. Further, risk reduction in athletes identified with CV disorders can be effectively achieved through modern strategies for risk stratification and disease-specific management. By every definition of the purpose of CV screening, ECG-inclusive programmes will better meet the stated objective of early detection when proper ECG interpretation and adequate cardiology resources are available. Less debate on screening protocols and more emphasis on advancing physician skills and infrastructure in sports cardiology is needed to more effectively screen targeted athlete populations.
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Background Data on the prevalence of acute illness in the period prior to a distance running race are limited. Currently, the presence of systemic symptoms (failed ‘neck check’) is used to advise athletes on participation. Aim To determine (1) the period prevalence of pre-race acute illness symptoms before a distance running event, (2) if symptomatic runners receiving educational material on acute illness did not start (DNS) the race and (3) if symptomatic runners who chose to start the race, did not finish (DNF) the race. Methods 7031 runners completed an online pre-race acute illness questionnaire in the 3–5 day period prior to a race. Symptomatic runners received educational information on exercise and acute illness. Runners were followed prospectively to determine DNS and DNF risk. Results 1338 runners (19.0%) reporting symptoms (7.5% reporting systemic symptoms—failed ‘neck check’) and receiving educational information had a higher DNS frequency (11.0%) compared to controls (6.6%)(p=0.0002). Symptomatic runners who started the race had a higher DNF frequency (2.1%) compared to controls (1.3%) (p=0.0346), particularly runners with systemic symptoms (2.4%; RR=1.90). Conclusions In summary, 19% (1 in 5) runners reported pre-race acute illness symptoms, with 7.5% (1 in 13) reporting systemic symptoms. Although runner education reduced the percentage symptomatic race starters, the majority of them still chose to race, resulting in a two times higher risk of not finishing in those with systemic symptoms. Pre-race acute illness symptoms are common; an educational intervention affects an athlete's decision to compete yet most symptomatic runners still competed, and systemic symptoms negatively affect performance, with possible health implications.
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Background: Increased physical activity (PA) is associated with improved quality of life and reductions in cardiovascular (CV) morbidity and all-cause mortality in the general population in a dose-response manner. However, PA acutely increases the risk of adverse CV event or sudden cardiac death (SCD) above levels expected at rest. We review the likelihood of adverse CV events related to exercise in apparently healthy adults and strategies for prevention, and contextualize our understanding of the long-term risk reduction conferred from PA. Methods: A systematic review of the literature was performed using electronic databases; additional hand-picked relevant articles from reference lists and additional sources were included after the search. Results: The incidence of adverse CV events in adults is extremely low during and immediately after PA of varying types and intensities and is significantly lower in those with long-standing PA experience. The risk of SCD and nonfatal events during and immediately after PA remains extremely low (well below 0.01 per 10,000 participant hours); increasing age and PA intensity are associated with greater risk. In most cases of exercise-related SCD, occult CV disease is present and SCD is typically the first clinical event. Conclusions: Exercise acutely increases the risk of adverse CV events, with greater risk associated with vigorous intensity. The risks of an adverse CV event during and immediately after exercise are outweighed by the health benefits of vigorous exercise performed regularly. A key challenge remains the identification of occult structural heart disease and inheritable conditions that increase the chances of lethal arrhythmias during exercise.
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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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Aim: Long distance running races are associated with a low risk of life-threatening events much often attributed to hypertrophic cardiomyopathy. However, retrospective analyses of aetiology lack consistency. Methods and results: Incidence and aetiology of life-threatening/fatal events were assessed in long distance races in the prospective Registre des Accidents Cardiaques lors des courses d'Endurance (RACE Paris Registry) from October 2006 to September 2012. Characteristics of life-threatening/fatal events were analysed by interviewing survivors and reviewing medical records including post-mortem data of each case. Seventeen life-threatening events were identified of 511 880 runners of which two were fatal. The vast majority were cardiovascular events (13/17) occurring in experienced male runners [mean (±SD) age 43 ± 10 years], with infrequent cardiovascular risk factors, atypical warning symptoms prior to the race or negative treadmill test when performed. Acute myocardial ischaemia was the predominant aetiology (8 of 13) and led to immediate myocardial revascularization. All cases with initial shockable rhythm survived. There was no difference in event rate according to marathons vs. half-marathons and events were clustered at the end of the race. A meta-analysis of all available studies including the RACE Paris registry (n = 6) demonstrated a low prevalence of life-threatening events (0.75/100 000) and that presentation with non-shockable rhythm [OR = 29.9; 95% CI (4.0-222.5), P = 0.001] or non-ischaemic aetiology [OR = 6.4; 95% CI (1.4-28.8), P = 0.015] were associated with case-fatality. Conclusion: Life-threatening/fatal events during long distance races are rare, most often unpredictable and mainly due to acute myocardial ischaemia. Presentation with non-shockable rhythm and non-ischaemic aetiology are the major determinant of case fatality.
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This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.
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The purpose of the American College of Sports Medicine's (ACSM) exercise preparticipation health screening process is to identify individuals who may be at elevated risk for exercise-related sudden cardiac death and/or acute myocardial infarction. Recent studies have suggested that using the current ACSM exercise preparticipation health screening guidelines can result in excessive physician referrals, possibly creating a barrier to exercise participation. In addition, there is considerable evidence that exercise is safe for most people and has many associated health and fitness benefits; exercise-related cardiovascular events are often preceded by warning signs/symptoms; and the cardiovascular risks associated with exercise lessen as individuals become more physically active/fit. Consequently, a scientific roundtable was convened by the ACSM in June 2014 to evaluate the current exercise preparticipation health screening recommendations. The roundtable proposed a new evidence-informed model for exercise preparticipation health screening on the basis of three factors: 1) the individual's current level of physical activity, 2) presence of signs or symptoms and/or known cardiovascular, metabolic, or renal disease, and 3) desired exercise intensity, as these variables have been identified as risk modulators of exercise-related cardiovascular events. Identifying cardiovascular disease risk factors remains an important objective of overall disease prevention and management, but risk factor profiling is no longer included in the exercise preparticipation health screening process. The new ACSM exercise preparticipation health screening recommendations reduce possible unnecessary barriers to adopting and maintaining a regular exercise program, a lifestyle of habitual physical activity, or both, and thereby emphasize the important public health message that regular physical activity is important for all individuals.
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In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation. Primary recommendation: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]
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Exercise-associated hyponatremia (EAH) is dilutional hyponatremia, a variant of inappropriate antidiuretic hormone secretion (SIADH), characterized by a plasma concentration of sodium lower than 135 mEq/L. The prevalence of EAH is common in endurance (<6 hours) and ultra-endurance events (>6 hours in duration), in which both athletes and medical providers need to be aware of risk factors, symptom presentation, and management. The development of EAH is a combination of excessive water intake, inadequate suppression of the secretion of the antidiuretic hormone (ADH) (due to non osmotic stimuli), long race duration, and very high or very low ambient temperatures. Additional risk factors include female gender, slower race times, and use of nonsteroidal anti-inflammatory drugs. Signs and symptoms of EAH include nausea, vomiting, confusion, headache and seizures; it may result in severe clinical conditions associated with pulmonary and cerebral edema, respiratory failure and death. A rapid diagnosis and appropriate treatment with a hypertonic saline solution is essential in the severe form to ensure a positive outcome.
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Exercise-associated hyponatremia (EAH), rhabdomyolysis and renal failure appear to be a unique problem in ultra-endurance racers. We investigated the combined occurrence of EAH and rhabdomyolysis in seven different ultra-endurance races and disciplines (i.e. multi-stage mountain biking, 24-h mountain biking, 24-h ultra-running and 100-km ultra-running). Two (15.4 %) ultra-runners (man and woman) from hyponatremic ultra-athletes (n = 13) and four (4 %) ultra-runners (four men) from the normonatremic group (n = 100) showed rhabdomyolysis following elevated blood creatine kinase (CK) levels > 10,000 U/L without the development of renal failure and the necessity of a medical treatment. Post-race creatine kinase, plasma and urine creatinine significantly increased, while plasma [Na(+)] and creatine clearance decreased in hyponatremic and normonatremic athletes, respectively. The percentage increase of CK was higher in the hyponatremic compared to the normonatremic group (P < 0.05). Post-race CK levels were higher in ultra-runners compared to mountain bikers (P < 0.01), in faster normonatremic (P < 0.05) and older and more experienced hyponatremic ultra-athletes (P < 0.05). In all finishers, pre-race plasma [K(+)] was related to post-race CK (P < 0.05). Hyponatremic ultra-athletes tended to develop exercise-induced rhabdomyolysis more frequently than normonatremic ultra-athletes. Ultra-runners tended to develop rhabdomyolysis more frequently than mountain bikers. We found no association between post-race plasma [Na(+)] and CK concentration in both hypo- and normonatremic ultra-athletes.
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In 1980, 1700 people died during a prolonged heat wave in a region under-prepared for heat illness prevention. Dramatically underreported, heat-related pathology contributes to significant morbidity as well as occasional mortality in athletic, elderly, paediatric and disabled populations. Among US high school athletes, heat illness is the third leading cause of death. Significant risk factors for heat illness include dehydration, hot and humid climate, obesity, low physical fitness, lack of acclimatisation, previous history of heat stroke, sleep deprivation, medications (especially diuretics or antidepressants), sweat gland dysfunction, and upper respiratory or gastrointestinal illness. Many of these risk factors can be addressed with education and awareness of patients at risk. Dehydration, with fluid loss occasionally as high as 6–10% of bodyweight, appears to be one of the most common risk factors for heat illness in patients exercising in the heat. Core body temperature has been shown to rise an additional 0.15–0.2°C for every 1% of bodyweight lost to dehydration during exercise. Identifying athletes at risk, limiting environmental exposure, and monitoring closely for signs and symptoms are all important components of preventing heat illness. However, monitoring hydration status and early intervention may be the most important factors in preventing severe heat illness.
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There is evidence for a higher prevalence of atrial fibrillation (AF) in athletes engaged in long-term endurance sports training compared with the general population. Although atrial anatomic adaptations, alterations in autonomic nervous system, chronic systemic inflammation and fibrosis have been proposed as potential mechanisms, they remain speculative. Medical therapy with long-term antiarrhythmic agents or ‘pill in the pocket’ medications is hampered by limitations, such as sports eligibility and interference with exercise tolerance. AF ablation represents a valid therapeutic option with results similar to these achieved in other patients. Nevertheless, further clinical trials are needed to confirm whether endurance sport practice affects the maintenance of sinus rhythm following catheter ablation of AF.
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Background Two important causes of sudden death during endurance races are arrhythmic death and heat stroke. However, “arrhythmic death” has caught practically all the attention of the medical community whereas the importance of heat stroke is less appreciated. Objectives The study sought to determine what percentage of life-threatening events during endurance races are due to heat stroke or cardiac causes. Methods This retrospective study examined all the long distance popular races that took place in Tel Aviv from March 2007 to November 2013. The number of athletes at risk was known. The number of athletes developing serious sport-related events and requiring hospitalization was known. Life-threatening events were those requiring mechanical ventilation and hospitalization in intensive care units. Results Overall, 137,580 runners participated in long distance races during the study period. There were only 2 serious cardiac events (1 myocardial infarction and 1 hypotensive supraventricular tachyarrhythmia), neither of which were fatal or life threatening. In contrast, there were 21 serious cases of heat stroke, including 2 that were fatal and 12 that were life threatening. One of the heat stroke fatalities presented with cardiac arrest without previous warning. Conclusions In our cohort of athletes participating in endurance sports, for every serious cardiac adverse event, there were 10 serious events related to heat stroke. One of the heat stroke–related fatalities presented with unheralded cardiac arrest. Our results put in a different perspective the ongoing debate about the role of pre-participation electrocardiographic screening for the prevention of sudden death in athletes.
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Sudden cardiac death (SCD) is the leading medical cause of death in athletes; however, the precise incidence is unknown. The objectives of this review were to examine studies on the rate of SCD in athletes, assess the methodological strengths and weaknesses used to arrive at estimates, compare studies in athletes with estimates in similar populations and arrive at an approximation of the incidence of SCD based on the best available evidence. A comprehensive literature search was performed in PubMed using key terms related to SCD in athletes. Articles were reviewed for relevance and included if they contained information on the incidence of SCD in athletes or young persons up to the age of 40. The reference list from each manuscript was reviewed for additional relevant articles. The methods for case identification were examined, as well as the inclusion and exclusion criteria and the precision of the population denominator studied. Thirteen studies were found investigating the rate of SCD in athletes who ranged in age from 9 to 40. An additional 15 incidence studies were located examining the rate of SCD in other populations under the age of 40. Rates of SCD varied from 1:917 000 to 1:3000. Studies with higher methodological quality consistently yielded incidence rates in the range of 1:40 000 to 1:80 000. Some athlete subgroups, specifically men, African-American/black athletes and basketball players, appear to be at higher risk. The incidence of SCD in athletes is likely higher than traditional estimates which may impact the development of more effective prevention strategies.
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It is important to identify risk factors associated with medical complications during ultra-marathons so that prevention programmes can be developed. To determine risk factors for medical complications during ultra-marathons. Prospective study. Two Oceans ultra-marathon (56 km) races. 26 354 race starters. Medical complications (defined as any runner requiring assessment by a doctor at the race medical facility or a local hospital on race day) were recorded over 4 years. Complications were subdivided according to the system that was affected and by final diagnosis. A Poisson regression model was used to determine risk factors for any medical complication and for more common specific complications. Risk factors for medical complications during 56 km road races were less running experience (≤1 medal vs 2-4 medals, p=0.0097), and both fastest (<6 vs 6-7 min/km, p=0.0051) and slowest (>7 vs 6-7 min/km, p<0.0001) running pace category. Year of observation was also associated with risk of complications (2009 vs 2008, p=0.0176; 2009 vs 2010, p=0.0007; 2010 vs 2011, p=0.0112). Risk factors for specific common medical complications were: postural hypotension (slowest pace), serious exercise-associated muscle cramping (older age, fastest pace), gastrointestinal complications (slowest pace) and dermatological complications (fastest pace). Less experience and running at either a slow or a fast pace were risk factors for complications during 56 km road running. Annual variation may also affect risk. Risk factors for specific medical complications were also identified. These data form the basis of further studies to assist medical staff to plan appropriate care at races.
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Regular participation in physical activity is well established as an important component of a comprehensive lifestyle intervention programme for primary, secondary and tertiary prevention of chronic non-communicable disease.1-3 Recreational distance running, as one form of regular physical activity, is popular globally. Data published in the 2013 Running USA Annual report indicates that there are over 50 million runners in the USA, of which >29 million run for more than 50 days/annum, and >9 million runners run for more than 110 days/annum (2013 Running USA Annual report: http://www.runningusa.org). Furthermore, almost 75% of male and female runners indicated that the main motivation to continue to run is to stay healthy. The half marathon race is the most popular event and participation in this race has also experienced the greatest growth between 2000 and 2012. Apart from the general increase in the number of runners, there is also a concomitant increase in participation in mass community-based distance running events globally. In 2012 there were more than 30 half-marathon races and more than 10 marathon races that attracted >20 000 runners (2013 Running USA Annual report: http://www.runningusa.org). However, it is also well documented that vigorous (high intensity) physical activity, such as distance running, is associated with medical complications that can affect a variety of organ systems.4 Of particular interest is the fact that vigorous exercise may act as a trigger for cardiac arrest and sudden death as a result … [Full text of this article]
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Cardiac arrest and sudden death during distance-running events have been reported but other medical complications, including serious life-threatening complications have not been well described. To document the incidence and nature of medical complications during 21 and 56 km running races. Prospective study. Two Oceans Marathon races (21 and 56 km races). 65 865 race starters (39 511-21 km runners, 26 354-56 km runners). Medical complications (defined as any runner requiring assessment by a doctor at the race medical facility or a local hospital on race day) were recorded in each of the 4 years of the study period. Complications were further subdivided into serious (potentially life-threatening) complications and deaths and were also analysed by system and final diagnosis. In the 4 years, 545 medical complications were recorded, resulting in an overall incidence (per 1000 race starters) of 8.27. The incidence of serious (potentially life-threatening) medical complications was 0.56 (37 serious complications). Two deaths occurred in 21 km runners (incidence of 0.05). The most common specific medical complications were exercise-associated collapse (postural hypotension), dermatological conditions, musculoskeletal injuries and serious exercise-associated muscle cramping. The incidence of medical complications was higher in 56 km runners but sudden cardiac deaths only occurred in 21 km runners. Serious medical complications were as common in 21 km as in 56 km runners. Risk factors for medical complications need to be determined in 21 and 56 km runners to plan strategies to reduce the risk of adverse medical events in endurance runners.
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There is evidence for a higher prevalence of atrial fibrillation (AF) in athletes engaged in long-term endurance sports training compared with the general population. Although atrial anatomic adaptations, alterations in autonomic nervous system, chronic systemic inflammation and fibrosis have been proposed as potential mechanisms, they remain speculative. Medical therapy with long-term antiarrhythmic agents or ‘pill in the pocket’ medications is hampered by limitations, such as sports eligibility and interference with exercise tolerance. AF ablation represents a valid therapeutic option with results similar to these achieved in other patients. Nevertheless, further clinical trials are needed to confirm whether endurance sport practice affects the maintenance of sinus rhythm following catheter ablation of AF.
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Objective: To determine the incidence and etiology of sudden cardiac arrest and death (SCA/D) in US high school athletes. Patients and methods: A prospective media database of SCA/D was queried for cases aged 14 to 18 years from 7 states over 6 school years (September 1, 2007, to August 30, 2013). Event details were investigated to determine participation on a high school athletic team, sex, sport, and occurrence during school-sponsored activity or exertion. National sports participation numbers were used and a conversion factor was applied to account for multisport athletes. Autopsy reports were reviewed and cause of death was adjudicated by an expert panel. Results: A total of 16,390,409 million athlete-seasons representing 6,974,640 athlete-years (AY) were examined, encompassing 36% of the total US high school athlete population. A total of 104 cases of SCA/D were identified (35 SCA with survival and 69 sudden cardiac deaths [SCDs]). The rate of SCD was 1:101,082 AY and of SCA/D 1:67,064 AY. Eighty-eight percent (92) of events occurred in male athletes. The rate of SCA/D in male athletes was 1:44,832 AY and in female athletes 1:237,510 AY (incidence rate ratio, 5.3; 95% CI, 2.9-10.6; P<.001). Men's basketball was the highest risk sport with an SCA/D incidence of 1:37,087 AY followed by men's football at 1:86,494 AY. Men's basketball and football athletes accounted for 57% (39) of deaths. Eighty percent of SCDs (55 of 69) were exertional and 55% (38 of 69) occurred while playing for a school-sponsored team. Autopsy reports were obtained in 73% (50) of cases. The most common findings of autopsy were idiopathic left ventricular hypertrophy or possible cardiomyopathy (13 of 50 [26%]), autopsy-negative sudden unexplained death (9 of 50 [18%]), hypertrophic cardiomyopathy (7 of 50 [14%]), and myocarditis (7 of 50 [14%]). Conclusion: The rate of SCA/D in male high school athletes was 1:44,832 AY, with almost half due to possible or confirmed cardiomyopathy disease. It is likely that many cases were not identified because of reliance on media reports, and these numbers represent a minimum estimate.
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Background: Debatably, the most commonly prescribed lifestyle modification for cardiovascular health involves daily exercise training (ET) and physical activity. Exercise has numerous known health benefits on blood pressure, lipid profile, weight loss, and glucose metabolism. However, controversy exists regarding the link between excessive endurance ET and harmful cardiac effects. Methods: We review the current literature and discuss the numerous known adverse effects of endurance ET on cardiac function. Results: Excessive endurance ET may negatively affect cardiac anatomy, play a role in osteoarthritis and coronary artery disease development, and increase the risks of cardiac arrhythmia and sudden cardiac death. Conclusion: More ET may not always be better when it comes to endurance ET, and optimal ET dosing regimens are clearly needed.
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Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.
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Background: Accurate knowledge of causes of sudden cardiac death (SCD) in athletes and its precipitating factors is necessary to establish preventative strategies. Objectives: This study investigated causes of SCD and their association with intensive physical activity in a large cohort of athletes. Methods: Between 1994 and 2014, 357 consecutive cases of athletes who died suddenly (mean 29 ± 11 years of age, 92% males, 76% Caucasian, 69% competitive) were referred to our cardiac pathology center. All subjects underwent detailed post-mortem evaluation, including histological analysis by an expert cardiac pathologist. Clinical information was obtained from referring coroners. Results: Sudden arrhythmic death syndrome (SADS) was the most prevalent cause of death (n = 149 [42%]). Myocardial disease was detected in 40% of cases, including idiopathic left ventricular hypertrophy (LVH) and/or fibrosis (n = 59, 16%); arrhythmogenic right ventricular cardiomyopathy (ARVC) (13%); and hypertrophic cardiomyopathy (HCM) (6%). Coronary artery anomalies occurred in 5% of cases. SADS and coronary artery anomalies affected predominantly young athletes (≤ 35 years of age), whereas myocardial disease was more common in older individuals. SCD during intense exertion occurred in 61% of cases; ARVC and left ventricular fibrosis most strongly predicted SCD during exertion. Conclusions: Conditions predisposing to SCD in sports demonstrate a significant age predilection. The strong association of ARVC and left ventricular fibrosis with exercise-induced SCD reinforces the need for early detection and abstinence from intense exercise. However, almost 40% of athletes die at rest, highlighting the need for complementary preventive strategies.
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We thank Drs Daniels and Burns for pointing out that coronary artery aneurysms were not included on the “Guidelines for Pathological Diagnosis.”1 The list was not meant to be inclusive, and many pathological entities that cause sudden cardiac death (SCD) in athletes, but not represented in this cohort, were not included. Other diagnoses assigned as a cause of death, but not included in the guidelines, were long QT syndrome, Wolff-Parkinson-White, and commotio cordis. In these cases, the cause of death was assigned given the circumstances of death and personal or family history. In this study, autopsy was available for …
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The health benefits of regular physical activity are irrefutable; virtually everyone can benefit from being active. The evidence is overwhelming with risk reductions of at least 20%-30% for more than 25 chronic medical conditions and premature mortality. Even higher risk reductions (ie, ≥ 50%) are observed when objective measures of physical fitness are taken. International physical activity guidelines generally recommend 150 minutes per week of moderate- to vigorous-intensity physical activity. A critical review of the literature indicates that half of this volume of physical activity might lead to marked health benefits. There is compelling evidence to support health promotion strategies that emphasize that health benefits can be accrued at a lower volume and/or intensity of physical activity. Public health policies are needed that reduce the barriers to physical activity participation such that everyone can reap the benefits of physical activity. It is also important to highlight that sedentary time (particularly sitting time) carries independent health risks. The simple message of “move more and sit less” likely is more understandable by contemporary society and is formed on the basis of a strong body of evidence. For practitioners who work directly with clients, it is recommended that an individualized prescription (dosage) that takes into consideration the unique characteristics and needs of the client is provided. Physical activity or exercise promotion should not be done in isolation; it should be part of an integrated approach to enhance healthy lifestyle behaviours.
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This is a case report of a highly trained, heat-acclimatized infantry soldier who suffered from exertional heatstroke during a 12-mile road march shortly after taking an ephedra-based supplement. Heatstroke is associated with systemic complications and a high mortality rate if not recognized early. Control of risk factors is key to the prevention of heatstroke. Since there are no clear ergogenic benefits in using ephedra alone, clinicians and military commanders should strongly discourage the use of ephedra-containing substances in active duty soldiers undergoing strenuous exercise.
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Objective: We described an organized, on-site medical response for a large-scale urban marathon event and documented illness/injury rates as well as ambulance transfer rates at the Vancouver International Marathon (VIM). Methods: Case-series report of medical encounters was documented prospectively over a 6-yr period at the VIM. The planning and organization of the on-site medical response is the main focus of this report. Results: A total of 67,402 runners participated in the VIM from 2006 to 2011. Over the 6-yr period, 2,986 patient encounters were documented. The patient presentation rate for the series was 45/1,000, the ambulance transfer rate was 0.09-0.58/1,000, and the medical transfer rate was 0.37-1.09/1,000. Conclusion: A coordinated on-site medical team covering the entire event site and race route was deployed to reduce the severity of illness and injury at a long-distance running event.
Article
Regular intensive exercise in athletes increases the relative risk of sudden cardiac death (SCD) compared with the relatively sedentary population. Most cases of SCD are due to silent cardiovascular diseases, and pre-participation screening of athletes at risk of SCD is thus of major importance. However, medical guidelines and recommendations differ widely between countries. In Italy, the National Health System recommends pre-participation screening for all competitive athletes including personal and family history, a physical examination, and a resting 12-lead electrocardiogram (ECG). In the United States, the American College of Cardiology and the American Heart Association recommend a pre-participation screening program limited to the use of specific questionnaires and a clinical examination. The value of a 12-lead ECG is debated based on issues surrounding cost-efficiency and feasibility. The aim of this review was to focus on (i) the incidence rate of cardiac diseases in relation to SCD; (ii) the value of conducting a questionnaire and a physical examination; (iii) the value of a 12-lead resting ECG; (iv) the importance of other cardiac evaluations in the prevention of SCD; and (v) the best practice for pre-participation screening.
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WHO developed the Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policy makers with guidance on the dose-response relationship between the frequency, duration, intensity, type and total amount of physical activity needed for the prevention of NCDs. The recommendations set out in this document address three age groups: 5-17 years old; 18-64 years old; and 65 years old and above. The section below includes the recommendations for each age group. For further information click below and download the complete document or click on the individual age groups for specific recommendations.
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Data from the London Marathon, with 650 000 completed runs, show that cardiac arrests occur even in the most experienced runners. Although coronary artery disease was the commonest cause of sudden cardiac arrest (SCA) with five deaths and six resuscitations, hypertrophic cardiomyopathy or idiopathic left ventricular hypertrophy (HCM) was diagnosed at autopsy on three occasions. HCM deaths had the same average age as the runners with ischaemic heart disease who had SCA or sudden cardiac death. The cardiac arrests were at the finish in less than one-third of cases and the remainder occurred between 6 and 26 miles on the course. Only one of the eight runners who died had reported symptoms to his family or physician suggestive of cardiac disease. The runner who had reported pre-race angina pain was investigated with a negative exercise stress test prior to the marathon and despite this died with a left anterior descending coronary artery stenosis. The cardiac death rate for the London Marathon is 1 in 80 000 finishers.
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-The incidence and etiology of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy (HCM) often reported as the most common etiology. -A database of all NCAA deaths (2003 - 2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4,242,519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16,508 AY) followed by medical causes (147, 29%, 1:28,861 AY). The most common medical cause of death was SCD (79, 15%, 1:53,703 AY). Males were at higher risk than females 1:37,790 AY vs. 1:121,593 AY (IRR 3.2, 95% CI, 1.9-5.5, p < .00001), and black athletes were at higher risk than white athletes 1:21,491 AY vs. 1:68,354 AY (IRR 3.2, 95% CI, 1.9-5.2, p < .00001). The incidence of SCD in Division 1 male basketball athletes was 1:5,200 AY. The most common findings at autopsy were autopsy negative sudden unexplained death (AN-SUD) in 16 (25%) and definitive evidence for HCM was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%) while percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. -The rate of SCD in NCAA athletes is high, with males, black athletes and basketball players at substantially higher risk. The most common finding at autopsy is AN-SUD. Media reports are more likely to capture high profile deaths, while insurance claims are not a reliable method for case identification.
Article
Although not performing on a professional level, amateur athletes, nevertheless, are participating in competitive sports and thus underlie a relevant risk for exercise-related SCD which implicates the need for an adequate pre-competition cardiac screening. As many amateur athletes belong to the category of "older" individuals, particularly CAD among male athletes with risk factors has to be targeted by the screening. However, the detection of clinically silent underlying coronary heart disease is challenging and cannot be accurately achieved by a standard screening provided to young athletes (history, clinical status, ECG). An extended work-up, at least, mandates the detection of cholesterol levels to estimate the individual cardiovascular risk. The fact that only less than 10% of Swiss amateur athletes have undergone cardiac screening led to various promising approaches to improve the awareness of the issue. Exemplarily, we successfully invented an "on-site" prevention campaign that positively influenced the attitude of the athletes towards cardiac screening. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
The overwhelming majority of sports-related sudden deaths occur among those older than 35 years of age. Because increasing numbers of older people are participating in organized endurance and competitive sporting events, the incidence of sports-related sudden death in older adults is expected to rise. Older athletes will approach clinical cardiologists for advice regarding their fitness for participation. It is important to recognize both that strenuous exercise is associated with a transient elevation in risk of sudden cardiac death and that appropriate training substantially reduces this risk. The approach to pre-participation screening for risk of sudden death in the older athlete is a complex issue and at present is largely focused on identifying inducible ischemia due to significant coronary disease. In this brief review, we summarize the current state of knowledge in this area with respect to epidemiology, mechanisms, and approaches to risk stratification, as viewed from the perspective of the consulting clinical cardiologist. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Article
Background The European Association of Cardiovascular Prevention and Rehabilitation (EACPR) recommends cardiovascular evaluation of middle-aged individuals engaged in sport activities. However, very few data exist concerning the impact of such position stand. We assessed the implications on workload, yield and economic costs of this preventive strategy. Methods Individuals aged 35–65 years engaged in high-intensity sports were examined following the EACPR protocol. Athletes with abnormal findings or considered at high-cardiovascular risk underwent additional examinations. The costs of the overall evaluation until diagnosis were calculated according to Swiss medical rates. Results 785 athletes (73% males, 46.8±7.3 years) were enrolled over a 13-month period. Among them, 14.3% required additional examinations: 5.1% because of abnormal ECG, 4.7% due to physical examination, 4.1% because of high-cardiovascular risk and 1.6% due to medical history. A new cardiovascular abnormality was established in 2.8% of athletes, severe hypercholesterolaemia in 1% and type 2 diabetes in 0.1%. Three (0.4%) athletes were considered ineligible for high-intensity sports, all of them discovered through an abnormal ECG. No athlete was diagnosed with significant coronary artery disease on the basis of a high-risk profile or an exercise ECG. The cost was US199perathleteandUS199 per athlete and US5052 per new finding. Conclusions Cardiovascular evaluation of middle-aged athletes detected a new cardiovascular abnormality in about 3% of participants and a high-cardiovascular risk profile in about 4%. Some of these warranted exclusion of the athlete from high-intensity sport. The overall evaluation seems to be feasible at reasonable costs.
Article
Objective: We described an organized, on-site medical response for a large-scale urban marathon event and documented illness/injury rates as well as ambulance transfer rates at the Vancouver International Marathon (VIM). Methods: Case-series report of medical encounters was documented prospectively over a 6-yr period at the VIM. The planning and organization of the on-site medical response is the main focus of this report. Results: A total of 67,402 runners participated in the VIM from 2006 to 2011. Over the 6-yr period, 2,986 patient encounters were documented. The patient presentation rate for the series was 45/1,000, the ambulance transfer rate was 0.09-0.58/1,000, and the medical transfer rate was 0.37-1.09/1,000. Conclusion: A coordinated on-site medical team covering the entire event site and race route was deployed to reduce the severity of illness and injury at a long-distance running event.
Article
A young male patient was admitted to our hospital with history of dysuria, recurrent vomiting, severe muscle pain and weakness which was induced by a session of rigorous exercise for the first time in the local gymnasium. He was subsequently diagnosed with exercise-induced acute kidney injury and rhabdomyolysis and managed accordingly. Later on during follow-up he was found to have extreme hypouricaemia (serum uric acid 0.2 mg/dl) and was subsequently diagnosed with renal hypouricaemia. Biochemical investigations on other family members of the patient revealed hereditary renal hypouricaemia in the family.
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Acute febrile illnesses are common in athletes over the course of training and competition seasons. Complete recovery and rapid yet safe return to participation are critical for competitive athletes. Alterations in thermoregulation, metabolism, fluid homeostasis, muscle strength, and endurance, as well as potential complications for the athlete and others, must be considered. The PubMed database was searched (1970-2013) for all English-language articles related to febrile illness in sport, using the keywords fever, febrile, body temperature, thermoregulation, infection, illness, disease, exercise, athlete, sport, performance, return to play, metabolism, hydration, and dehydration. Clinical review. Level 4. Limited data confirm that febrile illness is correlated with alterations in the body's thermoregulatory system, with increases in metabolic rate, and with effects in fluid homeostasis. Human and animal studies demonstrate a decrease in muscle strength and endurance secondary to muscle catabolism in febrile illness. However, indirect evidence suggests that regular exercise enhances the immune response. No strong clinical research has been published on return to play during or following acute febrile illness, excluding mononucleosis and myocarditis. Fever is correlated with an increase in insensible fluid losses, dehydration, metabolic demands, and dysregulation of body temperature. Fever can have detrimental effects on the musculoskeletal system, including decreasing strength and endurance, generalized muscle catabolism, and increase in perceived fatigue. Participating in strenuous exercise during febrile illness can worsen the illness and has demonstrated increased lethality in animal models. No consensus recommendations support return to activity before resolution of fever, and training should be resumed gradually once fever and dehydration have resolved.
Article
Although the American Heart Association / American College of Sports Medicine's Preparticipation Questionnaire (AAPQ) is a recommended pre-exercise cardiovascular screening tool, it has never been systematically evaluated. The purpose of this research is to provide preliminary evidence of its effectiveness among adults aged 40 years or older. Under the assumption that respondents would respond to AAPQ items as they responded to NHANES questionnaire responses, we calculated the gender- and age-specific proportions of adult participants in NHANES, 2001-2004 who would be receive a recommendation for physician consultation based on AAPQ referral criteria. Additionally, we compared recommended AAPQ referrals to a similar assessment using the Physical Activity Readiness Questionnaire (PAR-Q) in the study sample. AAPQ referral proportions were higher with older age. Across all age groups 40 years and older, 95.5% (94.3-96.8%) of women and 93.5% (92.2-94.7%) of men in the US would be advised to consult a physician before exercise. Prescription medication use and age were the most commonly selected items. When referral based on AAPQ was compared to that of the PAR-Q, the two screening tools produced similar results for 72.4% of respondents. These results suggest that more than 90% of US adults aged 40 years or older would receive a recommendation for physician consultation by the AAPQ. Excessive referral may present an unnecessary barrier to exercise adoption and stress the healthcare infrastructure.