Death and Cardiac Arrest in US Triathletes

Study Questions:

What are the rates of death and cardiac arrest among US triathletes?

Methods:

Among participants in US triathlon races from 1985 to 2016, data on deaths and cardiac arrests were assembled from sources such as the US National Registry of Sudden Death in Athletes (which uses news media, Internet searches, LexisNexis archival databases, and news clipping services) and USA Triathlon (USAT) records. The incidence of death or cardiac arrest in USAT-sanctioned races from 2006 to 2016 was calculated.

Results:

A total of 135 sudden deaths, resuscitated cardiac arrests, and trauma-related deaths were compiled; the mean (± SE) age of victims was 46.7 ± 12.4 years, and 85% were male. Most sudden deaths and cardiac arrests occurred in the swim segment (n = 90); the others occurred during bicycling (n = 7), running (n = 15), and postrace recovery (n = 8). Fifteen trauma-related deaths occurred during the bike segment. The incidence of death or cardiac arrest among 4,776,443 USAT participants was 1.74 per 100,000 participants (2.40 per 100,000 in men and 0.74 per 100,000 in women; p < 0.001). In men, risk increased substantially with age, and was much greater for those aged ≥60 years (18.6 per 100,000 participants). Death or cardiac arrest risk was similar for short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per 100,000 participants). Autopsy-confirmed noncardiovascular causes of death (n = 5) included heat stroke in 2, rhabdomyolysis in 1, and trauma in 2. At autopsy, 27 of 61 decedents (44%) had clinically relevant cardiovascular abnormalities, most frequently atherosclerotic coronary disease (CAD, n = 18 [67%]) , cardiomyopathy (n = 4 [15%], including probable hypertrophic cardiomyopathy [HCM] in 3 and arrhythmogenic right ventricular cardiomyopathy [ARVC] in 1); with fewer cases of myxomatous mitral valve disease (n = 2) and aortic or vascular rupture (n = 1).

Conclusions:

Deaths and cardiac arrests during triathlon events are not rare; most have occurred in middle-aged and older men, and most sudden deaths in triathletes happened during the swim segment. Clinically silent cardiovascular disease (predominantly atherosclerotic CAD, with fewer cases of suspected HCM, ARVC, myxomatous mitral valve disease, and aortic or vascular rupture) was present in a high proportion of decedents.

Perspective:

Using case series data, the incidence of death or cardiac arrest during US triathlons (1.74 per 100,000 participants) is low but not insubstantial; with higher rates in men (2.40 per 100,000 participants) than women (0.74 per 100,000 participants), and substantially increased risk in older men (18.6 per 100,000 men ≥60 years of age). These data suggest that additional measures aimed at reducing death risk among triathletes could be of interest, potentially including minimum standards for medical presence during races, water quality, on-water rescuers during the swim event, and coordination with local emergency services.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Vascular Medicine, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Exercise

Keywords: Acute Coronary Syndrome, Aortic Rupture, Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Atherosclerosis, Athletes, Autopsy, Bicycling, Cardiomyopathy, Hypertrophic, Cause of Death, Coronary Artery Disease, Death, Sudden, Exercise, Heart Arrest, Heart Failure, Heat Stroke, Ischemia, Primary Prevention, Rhabdomyolysis, Running, Sports


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