Readers here at the blog will know that I’ve had a long-standing interest in triathlon fatalities. My interest was originally sparked by media reports and the paradox that seemingly healthy and fit triathletes might die on race day.
I was involved with an internal review of this problem at USA Triathlon (USAT), the governing body for the sport of triathlon in the United States. In 2011, that task force issued a formal report and set of recommendations for athletes, event organizers, and USAT itself. Those written recommendations are still valuable today as we work to reduce the number of triathlon race-related fatalities.
In this week’s edition of Annals of Internal Medicine, I joined with Drs. Kevin Harris and Barry Maron from the Minneapolis Heart Institute in reporting on “Death and Cardiac Arrest in U.S. Triathlon Participants, 1985-2016: A Case Series.” In this scientific report, we’ve gathered information about 122 athletes who died and another 13 athletes who suffered cardiac arrest but survived during triathlon races in the United States over the past 3 decades. This is, by far, the most comprehensive scientific report on this subject.
Special thanks go to the leadership at USAT which recognized the importance of this issue, has been proactive in working to reduce the number of race-related fatalities, and was extraordinarily helpful to our investigative team as we assembled the information for our new report.
The Important Observations
- Victims were 47 +/- 12 years old
- 85% were men
- Almost 40% were first-time triathlon participants
- There were no elite or professional athletes among the victims
- The overall rate for fatalities or cardiac arrest was 1.74 per 100,000 participants (2.40 for men, 0.79 for women). For comparison, the rates of cardiac arrest (including fatalities) are approximately 1.0 per 100,000 participants in marathons and 0.3 per 100,000 participants in half marathons.
- The fatality risk in triathlon increases exponentially with age; the fatality rate was 18.6 per 100,000 participants among men 60+ years old
- Fatality rates were similar for short, intermediate, and long-distance races
- The majority of deaths (74%) occurred during the swim segment; smaller numbers of deaths occurred during the bike or run segments or after finishing the race
- Among 22 fatalities occurring during the bike segment, 15 were due to traumatic injuries
- At autopsy, clinically relevant (but presumably previously unrecognized) heart/vascular disease was found in many victims
A Recipe for Doing Better
We should focus on two strategies for reducing the number of fatalities: 1) we should work to prevent incidents of race-related cardiac arrest and 2) we should work to improve the survival rate for any such victims of cardiac arrest. Athletes, physicians, event organizers, safety personnel, and sport governing bodies can all play an important role.
Athletes should:
- Make certain that their participation in a particular race is in keeping with their health, both chronic and acute, as well as their ability and preparation.
- Consider their heart health before participating. This may be particularly true for first-time participants and for men who have reached middle age. For older men, testing for “hidden” coronary artery disease (CAD) or other forms of cardiovascular disease may be appropriate.
- Assess their health on race day and consider not racing if they are “sick.” Symptoms, particularly systemic symptoms like fever, are related to DNF rates in other sports settings.
- Be prepared for the rigors of a triathlon swim. It is important to be a capable swimmer and to have practiced open water swimming in advance of the race.
- Think to STOP at the first sign of medical troubles (unexplained shortness of breath, chest pain/discomfort, or light-headedness), particularly during the swim segment.
Physicians should:
- Be aware of the risks of participating in triathlon and be in a position to counsel their athlete patients about those risks in the context of the patient’s specific health situation.
- Consider the potential value of cardiac screening, particularly for occult CAD in men who have reached middle age. Evidence-based screening protocols are not yet available, so an approach will need to be individualized. In most cases, an evaluation of the traditional risk factors for CAD would be appropriate and in some cases, additional testing such as calcium-scoring cardiac CT or stress testing may be appropriate. Athletes who are just beginning an exercise program should receive special attention in this regard.
Event organizers should:
- Develop a robust safety plan, particularly for the swim segment, that enables prompt (near instantaneous) identification of a lifeless victim, and then rescue of that individual to a location where CPR, defibrillation, and advanced life support can be provided.
- Have a communication system for all individuals involved in race-day safety.
- Rehearse the safety response to a lifeless victim, especially for the swim segment.
Race-day safety officials should:
- Be trained in CPR and use of the AED.
- Be familiar, through rehearsal, with the communication and safety plans.
Sports governing bodies should:
- Provide education for athletes, event organizers, medical directors, and volunteer safety officials about life-threatening race-day emergencies.
- Develop rules and sanctioning requirements that promote athlete safety.
Reference:
- Harris KM, Creswell LL, Haas TS, Thomas T, Tung M, Isaacson E, Garberich RF, Maron BJ. Death and cardiac arrest in U.S. triathlon participants. Annals of Internal Medicine 2017 (in press).
Related Posts:
- Should You Race When You’re Sick?
- Triathlon Fatalities: 2013 in Review
- New USA Triathlon Water Temperature Safety Recommendations
- Fatal Arrhythmias in Open Water Swimming: What’s the Mechanism?
Has anyone looked into possible correlation between wetsuits and swim deaths? In a wetsuit-legal race, perhaps 95-98% of swimmers will wear one. (There’s a serious speed disadvantage if one doesn’t wear a wetsuit among a field of wetsuit-wearers; even “completers, not competers” don’t want to give up the bouyancy advantage.) I swam in a 70.3 on a hot sunny day in May in Tennessee when the water temp was deemed wetsuit-legal. I did not wear a wetsuit and was perfectly fine; I have swum in MUCH colder water temps sans wetsuit, and I would have gotten hot that day during swim had I worn one. I was one of VERY FEW swimmers not wearing a wetsuit that day. The line to get into the water was long and slow. Though participants did not pull up their wetsuits when they arrived at swim venue, by the time they were waiting in the hot, sunny line to get into the water, pretty much everyone had his or her wetsuit pulled all the way on and fully zipped up. (Talk about overheating and restrictive compression! Try standing on dry land in the sun wearing a wetsuit. Ugh! But no one ever examines the risk implications of this common race condition.) Same race: Just as the swimmer before me was about to jump off dock to start his swim, he froze. I looked where he was staring, and I froze too. Medics were bringing a dead swimmer out of the water, right there. TRAGIC. (Volunteer did an awesome job of distracting us, refocusing us, and getting us into the water.) It was later published that the deceased swimmer was ex-military, very fit, very comfortable with open-water swimming in race conditions. He had no known heart issues, but succumbed to cardio-death of some sort. I have ALWAYS WONDERED since that sad and disturbing race day if wearing a wetsuit on dry land in hot sun for a period of time prior to swim start (followed by swimming in water that truly did not seem cool enough to prevent overheating in a wetsuit) may have contributed to this athlete’s untimely and unexpected death. IMHO, race directors are way too quick to declare races wetsuit legal, because they know that they get bigger turnouts (and higher profits), if more people can rely on wetsuit bouyancy to resolve swimming angst. (Weaker swimmers more likely to try and continue with triathlons if they can wear wetsuits and feel in the crowd’s norm, instead of feeling as they’re using a crutch on the swim.) Without a doubt, if such races were made “wetsuit optional” but not “wetsuit legal”, then far fewer swimmers would wear wetsuits. ** SHOULD THE WATER’S UPPER TEMPERATURE LIMIT FOR WETSUIT-LEGAL BE LOWERED FROM 78 DEGREES TO SAVE LIVES BY REDUCING WETSUIT USE AND POSSIBLY PREVENTING OVERHEATING AND OVER-RESTRICTION DURING PRE-SWIM WAITS?** I’d love to see a doctor address this. This may well be an overlooked danger, hiding in plain sight, that could be easily rectified if someone in authority would examine the issue and call for changes, if needed.
Thank you so much for allowing me to bring my concerns to your attention.
Most of the swimming victims were wearing a wetsuit, perhaps simply because most triathlon swims are “wetsuit legal.” I don’t believe there are compelling data that implicate wetsuit use, though, as a cause of swimming deaths.
The majority of swimming fatalities occurred in temperate water; for cases where we could identify the water temperature, the mean temperature was 71F.
Has someone used correlation analysis to determine if there is a correlation between water temperature and death ? There might be in the segment of higher temperatures. There might also be an inverse correlation ( in the part of the data relating to lower temperatures) Did someone review a scatterplot of this data in an effort to look into this ? Certainly temperature extremes can have an effect on cardiac arrest. I think that is what sqrrlgrl was suggesting. Where do the USAT wetsuit guidelines come from anyhow ? Are they based on scientific data or just customary ? I have seen people wearing wetsuits at 83.9 degree temperatures ( which USAT allows). Would 83.9 degrees increase the risk for people with underlying heart disease ?
There appears to be no relationship between water temperature and the frequency of death during the swim segment.
For swim-related fatalities where the water temperature was available, the mean temperature was ~72 degrees.
The USAT rules for wetsuit use are arbitrary. In triathlon as well as open water swimming, the wetsuit rules vary from country to country.