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Should we stop Phidippides?

Daniel Neunhaeuserer, Sports Cardiology Quiz Section Co-Editor

Long distance running and the participation in marathons has become more and more popular in the general population. There is clear evidence about the positive effects of sports and exercise on health and disease, but can it be also too much in certain circumstances?

Pills of History: Phidippides is the central figure in the story that inspired a modern sporting event, the marathon race. Phidippides is said to have run from Marathon to Athens to deliver news of the victory of the battle of Marathon (1). 

Rehabilitation and Sports Cardiology
Risk Factors and Prevention

The case

A 55-year old ultra-athlete, also named Phidippides, came to our attention for pre-participation screening. His training history was impressive; in 22 years of exercise training, he has run about 41,000 km and cycled almost 16,000 km, i.e. 1.42 circumferences of the earth. He participated in different ultra-marathons and marathons, with a peak of 10 marathons a year (Figure 1).

Figure 1: Patient's last 22 years of endurance sports activity


Figure 1a shows the km covered by Phidippides (blue columns show running km, red columns show cycling km). Figure 1b shows the number of his endurance events (blue columns show marathons and red columns show ultramarathons).

No pathological findings during resting evaluation were found and basal ECG was normal for an athlete (Figure 2). 

Figure 2: Resting ECG


As recommended by the Italian COCIS 2017 Guidelines (2), a maximal exercise test was performed for the mandatory preparticipation screening in master athletes as well as for sports-medical counselling (3). During the test, the ECG showed frequent premature ventricular contractions (PVCs) conducted as RBBB - inferior axis (Figure 3a) and two similar couples of PVCs in the early recovery phase (Figure 3b).

Figure 3: Premature ventricular contractions (PVCs) during exercise test


Figure 3a


Figure 3b

Further investigations revealed a mild mitral valve prolapse (MVP) with a minimum regurgitation on echocardiography and frequent PVCs and a short run of monomorphic ventricular tachycardia (Figure 4) on 24-hour ECG Holter monitoring; PVCs were exclusively registered during exercise and recovery.

Figure 4: Run of monomorphic ventricular tachycardia recorded during the exercise/recovery phase of 24 h ECG-Holter monitoring


The cardiac magnetic resonance (CMR) detected an isolated late gadolinium enhancement (LGE) in the anterior papillary muscle of the left ventricle suggestive of a non-ischaemic endomyocardial fibrosis (Figure 5).

Figure 5: late gadolinium enhancement (LGE) in the anterior papillary muscle of the left ventricle on CMR


Cardiac CT angiography showed normal coronary circulation.

It is known that a severe MVP might induce regionalised myocardial fibrosis and could thus lead to ventricular arrythmias. However, the case suggests that a huge volume of strenuous exercise might lead in certain clinical conditions such as a mild MVP, to morphological maladaptations which could become responsible for potentially dangerous arrhythmias in the long-term.

But what should we do with our patient Phidippides? Should he stop his sports activity?

Test your knowledge

Note: The views and opinions expressed on this page are those of the author and may not be accepted by others. While every attempt is made to keep the information up to date, there is always going to be a lag in updating information. The reader is encouraged to read this in conjunction with appropriate ESC Guidelines. The material on this page is for educational purposes and is not for use as a definitive management strategy in the care of patients. Quiz material on the site are only examples and do not guarantee outcomes from formal examinations.


1. Castelletti S, E Pieles G. The athlete's heart from Philippides to the modern marathon runners. European Heart Journal (2022) 43, 2538–2541.

2. Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility, 2017.

3. Giulia Quinto, Daniel Neunhaeuserer, Andrea Gasperetti, Francesca Battista, Giulia Foccardi, Veronica Baioccato, Stefano Gobbo, Marco Bergamin & Andrea Ermolao (2021): Can exercise test intensity and modality affect the prevalence of arrhythmic events in young athletes?, Research in Sports Medicine, DOI: 10.1080/15438627.2021.1937162.

4. Domenico Corrado, Jonathan A Drezner, Flavio D’Ascenzi, Alessandro Zorzi. How to evaluate premature ventricular beats in the athlete: critical review and proposal of diagnostic algorithm. 2020;54:1142-1148.

5. Yamada T et al. Ventricular fibrillation induced by a radiofrequency energy delivery for idiopathic premature ventricular contractions arising from the left ventricular anterior papillary muscle. Europace 2009; 11:1115-1117

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7. Trivax, J. E. and McCullough, P. A. (2012), Phidippides Cardiomyopathy: A Review and Case Illustration. Clin Cardiol, 35: 69–73.

8. P. Baker et al. Exercise-induced cardiac troponin elevation: An update on the evidence, mechanism and implications. IJC Heart e Vasculature 22 (2019) 181-186.

9. Oikonomou E, The aetiology of death for marathon runner Phidippides? Eur Heart J, 2019 Aug 14;40(31):2564-2565.

10. Ermolao A, Gasperetti A. Comparison of cardiovascular screening guidelines for middle-aged/older adults. Scand J Med Sci Sports. 2019 Sep;29(9):1375-1382.

11. Wall EE, Schalij MJ. Mitral valve prolapse: a source of arrhythmias? Int J Cardiovasc Imaging. 2010;26:147–149.

12. Turker Y, Ozdayin M, Acar G, et al. Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging. 2010;26:139–145

13. Yuchi Han, et al. Evaluation of Papillary Muscle Function Using Cardiovascular Magnetic Resonance Imaging in Mitral Valve Prolapse. Am J Cardiol. 2010 July 15; 106(2).

14. Chen Y, Serfass RC, Mackey-Bojack SM, et al. Cardiac troponin T alterations in myocardium and serum of rats after stressful, prolonged intense exercise. J. Appl. Physiol. 2000; 88:1749Y55.

15. Heidbuchel H, Hoogsteen J, Fagard R, et al. High prevalence of right ventricular involvement in endurance athletes with ventricular arrhythmias. Role of an electrophysiologic study in risk stratification. Eur. Heart J. 2003;24:1473Y80.

Notes to editor

Author information:

Marta Fabris, MD
Giulia Quinto, MD 
Marco Vecchiato, MD
Andrea Ermolao, MD
Daniel Neunhaeuserer, MD, PhD

Sports and Exercise Medicine Division, Department of Medicine, University of Padova.

Sports and Exercise Medicine Clinical Network of Veneto Region, Italy.