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Should we really be concerned about cardiovascular events in endurance running races?

Comment by Luis Serratosa, EAPC Sports Cardiology Section member

Endurance running races (ERR) have become increasingly popular with the number of organised races having increased by up to 20-fold in the last decades in many countries. Cardiovascular disease is the leading cause of death in developed countries and the multiple benefits of physical activity for cardiovascular health might be one of the reasons behind the increased popularity of endurance running. Although the previously reported risk of cardiovascular events and sudden cardiac death in long distance races seems to be low, there is still increased concern because as more and more people engage in ERR, more of those participants could have an underlying cardiovascular disease.

Sports Cardiology

This is a prospective study in which the authors analysed the prevalence, patient risk profile and outcome, of life-threatening/fatal events occurring during the 25 main Parisian ERR (16 km to marathon distance) between October 2006 and April 2012. Results are part of the ongoing RACE Paris registry, an exhaustive one which registers all deaths and life-threatening events occurring 30 min before, during or within 2 h after the end of the race, in participants of 18 years old or more.

A total of 13 of the 17 life-threatening events registered among the 511.880 preselected runners, were major cardiovascular adverse events (9 cardiac arrest, 1 shock due to exertional heat stroke, 2 ongoing acute myocardial infarction and 1 ventricular tachycardia). Although still low, the registered cardiovascular event rate (2.5/100.000) is among the highest ever reported. Acute myocardial ischemia (AMI) was the predominant cause, affecting 8 of 13 (1.6/100.000), all male aged 40 years or more with few cardiovascular risk factors. Cardiac events were more likely to occur during the last part of the race, and incidence did not differ between marathons and half marathons.

In addition to the low incidence of total life-threatening events and major cardiovascular events, the other good news is that all 9 cardiac arrests were witnessed and resuscitation was immediately started by bystanders and/or the race emergency medical services. Initial presentation with asystole led to death in 2 of 3 cases, but once more, prompt medical management was proven to be an effective strategy as all 6 with a shockable rhythm (ventricular fibrillation) were successfully resuscitated. Of the 2 deaths, one was due to arrhythmogenic right ventricular cardiomyopathy and the other one to AMI.

When the RACE Paris registry was included in a meta-analysis with 5 other studies (12.540.669 runners), the low prevalence of life-threatening events (0.75/100.000) during ERR was corroborated and fatality confirmed to be higher when non shockable rhythm at presentation and non-ischaemic aetiology.
Another key finding of the study is that the majority of the registered major cardiovascular events were unpredictable with only 1 having reported typical chest pain on exercise one month before. Four had negative valid stress tests before the race, including 2 who had complained of shortness of breath and low performance.

According to the results of the RACE Paris registry, we can confirm that although the number of recreational runners participating in ERR has increased exponentially in the last 2 decades, the prevalence of life-threatening and cardiovascular events seems to remain low and similar to that reported in previous studies. Immediate response and on-site resuscitation are the most effective strategies to reach good survival rates. In spite of the poor predictability in the RACE Paris registry, ischemia related symptoms might also be of help when assessing participants before ERR.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.


Registry on acute cardiovascular events during endurance running races: the prospective RACE Paris registry (full text pdf)

Gerardin B, Collet JP, Mustafic H et al.
Eur Heart J (2016) 37, 2531–2541. doi:10.1093/eurheartj/ehv675