Athletes & preventive care

New Study Confirms Value and Raises Questions About Cardiac Screening for Young, Competitive Athletes

August 9, 2018 By Larry Creswell, MD Leave a Comment

SoccerSCD

In a study reported today in the New England Journal of Medicine, Dr. Sanjay Sharma and colleagues from the University of London offer the most comprehensive look yet at the utility of cardiac screening for young, competitive athletes—in this case, specifically for elite, adolescent British soccer players.

We’ve long known about the small risk of sudden cardiac death (SCD) among young, competitive athletes, but very few datasets have been assembled to look carefully at the value of cardiac screening in these athletes.

The Study

Over a 20-year period from 1996 through 2016, the English Football Association used a combination of health questionnaire, physical examination, electrocardiogram (ECG), and echocardiogram to assess the heart health of all 11,168 potential soccer players, aged 15-17 years, who were joining the Association. Because the ECG and echocardiogram were included, we might characterize the cardiac screening as comprehensive, or “aggressive.” Information was then gathered about any of these players who later died, with a focus specifically on deaths due to heart-related conditions. The investigators were then able to return to the athlete victims’ initial cardiac screening to see what lessons could be learned.

The Findings

The investigators report that with the initial cardiac screening (with health questionnaire, physical examination, ECG, and echocardiogram):

The cost of the initial cardiac screening was $342 per athlete.
42 athletes (0.38%) were found to have cardiac diseases that could cause sudden cardiac death (SCD). Among these 42 athletes, all of those with forms of cardiomyopathy or long Q-T syndrome were advised not to participate in sports.
Another 225 athletes (2%) were found to have other, non life-threatening cardiac diseases such as heart valve problems or congenital heart conditions. In many cases, these athletes received medical or surgical treatment that allowed them to return to play.
A total of 830 athletes (7%) required additional testing to sort out any potential heart problems detected by the initial screening procedure.
After complete evaluation, 544 athletes (5%) required long-term monitoring for non life-threatening heart conditions.

During a follow-up period of 118,531 person-years, there were 23 deaths from any cause, including 8 from a cardiac cause. The incidence, then, of SCD in this cohort of athletes is 1 per 14,794, which is greater than previously reported for most young, competitive athletes and similar to the rate reported for NCAA basketball players. In this report, all 8 of the cardiac deaths were sudden and occurred during exercise. Among these 8 victims:

The deaths occurred anywhere from 0.1 to 13.2 years after the initial cardiac screening.
7 deaths (88%) were caused by hypertrophic cardiomyopathy (HCM), which is known to be associated with SCD.
- 5 of these 7 deaths due to HCM occurred in athletes with a completely normal screening examination.
- 2 of these 7 deaths due to HCM occurred in athletes in whom HCM was diagnosed at the initial screening, but who chose to continue to participate in sports and exercise gainst medical advice.

My Take

This study is important because it provides a “real world” look at the use of cardiac screening for young, competitive athletes.

Here, we see that an “aggressive” approach to cardiac screening that includes health questionnaire, physical examination, ECG, and echocardiogram is useful to identify athletes at risk for SCD as well as those who require some sort of evaluation and treatment for non life-threatening forms of heart disease. The findings of the study in this regard are not surprising.

In a setting in which comprehensive, long-term follow-up is possible, this study’s estimate of the risk of SCD among the screened athletes is likely to be very accurate. Moreover, the incidence of SCD at approximately 1 per 15,000 is a bit greater than previously thought. There should be no doubt, though, that the incidence of SCD will vary among different cohorts of athletes, of different abilities, and participating in different sports.

The study raises some worry, though, about the effectiveness of “aggressive” cardiac screening programs. First, it is not clear why 2 athletes diagnosed with HCM would be allowed to continue to participate against medical advice and it is truly sad that these athletes later died. But more worrisome, though, is the finding that 5 other athletes died because of HCM that was not detected during the cardiac screening. Review of ECGs of these athletes confirmed, in fact, that they were normal. Perhaps we have an undue faith in the ability of ECG and echocardiogram to identify HCM and other potentially life-threatening conditions. These findings raise the possibility that an initially negative cardiac screening cannot provide complete reassurance that athletes are risk-free for SCD and raise the question about the need for periodic cardiac re-testing in the years after an initially negative screen.

I think there will be a bunch of headlines in the press about this study and most of the reporting will focus on the athletes who died after a supposedly normal cardiac screening exam. We will need to keep in mind, though, the positives about cardiac screening—namely, the many other athletes who learned they had a variety of heart conditions that could be treated successfully and allow them to return to play.

Caution! The Six Warning Signs You Shouldn’t Ignore

February 24, 2018 By Larry Creswell, MD 16 Comments

Some readers here at the blog will remember that I once wrote a monthly column for Endurance Corner, a multisport coaching outfit. Many of the links to those articles are no longer active, as readers have pointed out. One of the most popular Endurance Corner articles was a 2010 article entitled “Caution! The Five Warning Signs You Shouldn’t Ignore.” I thought I’d update the article here at the blog, and include an additional, sixth warning sign that athletes should also be aware of.

Over the years, I’ve noticed that my athlete friends seem to be very “in touch” with their bodies. They can be hyper-vigilant about the first signs of “swimmer’s elbow” or plantar fasciitis or leg muscle strain. They’re also apt to be proactive about dealing with these problems. Maybe that’s just because it’s sometimes easy to self-diagnose a musculoskeletal problem and easy to self-prescribe rest, ice, or analgesics. Maybe over time, they’ve learned the lesson that early intervention can head off bigger problems later on. That’s an important lesson, too.

I’ve also noticed, though, that my athlete friends sometimes give short shrift to some of the warning signs of potentially more worrisome problems—problems that stem from the heart or cardiovascular system. In my experience, it seems that men are worse than women. Like I’ve mentioned in previous articles, young “healthy” men just don’t like to go to the doctor. It’s easy to think that we’re invincible and ignore serious warning signs until they simply can’t be ignored any longer. But just like plantar fasciitis, it’s always best to recognize and deal with any serious heart-related problem earlier rather than later.

Here’s my short list of six warning signs that you shouldn’t ignore. These are symptoms that you should discuss with your doctor. Get reassurance if there’s really no serious problem and get thoroughly evaluated if your doctor believes there may truly be something wrong.

Chest pain or discomfort. Once every few weeks I meet with a small group of third year medical students to talk about patient scenarios that involve chest surgery. One of the scenarios that we discuss deals with a young man with chest pain. I ask the medical students to come up with a list of the potential causes and I’m always amazed at how many answers are offered up. Sometimes they’re able to list 30 or more. That’s the way it is with chest pain—many, many potential causes. These include things like injuries to the chest, reflux disease of the stomach, inflammation of the joints between the ribs and breast bone, anxiety, and diseases of the esophagus, among others. The students are quick to remember the potentially life-threatening causes such as heart attack (acute myocardial infarction), collapse of one of the lungs (pneumothorax), tears (dissection) of the aorta, the large blood vessel that carries blood away from the heart, and pulmonary embolism, the condition where blood clots form and travel to the lungs. I suppose that any of these causes may be in play for an athlete with chest pain. But the particular scenario that’s most important for athletes is chest pain or discomfort that comes with exertion and is relieved by rest. This can be an indication of coronary artery disease (CAD) that is usually caused by plaque build-up in the coronary arteries that supply blood to the heart muscle itself. In its early stages, the pain can be very subtle, perhaps nothing more than a twinge. In its later stages, the pain can be crippling. The good news is that, working with your doctor, you can be evaluated to see if chest pain is due to CAD. A variety of treatments may be available depending upon your situation. Don’t ignore chest pain!
Unexplained shortness of breath. As athletes, we’re all short of breath at some point—some of us earlier than others. And as athletes, we usually become accustomed to the level of shortness of breath that is associated with a given workout or level of effort. What’s worrisome is when there is some change to that pattern—when shortness of breath is unexpectedly out of proportion to what you’d ordinarily expect. That’s when the alarm bells should go off inside your head. Just like chest pain, there are a myriad of causes of shortness of breath, ranging from pulmonary or bronchial infections, to asthma (potentially made worse with exercise), to blood clots in the lungs (pulmonary embolism). For athletes, the most worrisome sign might be shortness of breath that persists after exercise stops or shortness of breath that occurs at rest. Both are signs that a heart condition may be responsible. This is a warning sign that you should report to your doctor.
Loss of consciousness. Much of medical school involves learning a big vocabulary of new “medical” words. Our word for sudden, unexpected loss of consciousness is syncope. Patients will use a variety of terms like “blacking out,” “passing out,” “falling out,” or even just “lightheadedness” or “dizziness.” Again, there are many causes, such as dehydration, side effects of various medications, etc. For athletes, one common scenario is near-syncope or syncope at the end of a workout, when the exercise is stopped abruptly without a period of cooling down. Thankfully, that situation can be avoided just by remembering to have an appropriate cool-down after each workout. The most worrisome type of syncope occurs during exercise. This almost always indicates a serious underlying medical problem—and often related to the heart. All cases of syncope should be discussed with your doctor, but it’s particularly important (bordering on emergency) to be evaluated if you have syncope during exercise.
Unexplained fatigue. Like shortness of breath, all athletes are familiar with fatigue. Almost regardless of the sport, fatigue just comes with the territory. It’s important to remember that, besides exercise, there are many causes of fatigue, including depression, the side effects of various medications, and anemia, among others. It’s also true that fatigue can be a symptom of underlying heart disease. Athletes become accustomed to the degree of fatigue that is associated with any particular workout or load and they should be acutely aware when there is a change to this pattern. Whenever there is a sudden change in an athlete’s pattern of fatigue or when the fatigue persists for an excessively long time, it’s important to get evaluated. Find out what’s going on.
Palpitations. Of the first five of these warning signs, palpitations—the feeling of an abnormally strong, fast, or irregular heartbeat that just grabs your attention—is undoubtedly the most common among athletes. It’s an unusual problem in school-aged athletes, but is very common among middle-aged endurance athletes. In some reports, as many as 70% of adult athletes report this problem. The palpitations may occur during exercise or at rest. We could make a long list of specific arrhythmias (abnormal heartbeats) that explain palpitations in athletes. The most common problems are due to abnormal heartbeats or rhythms (like atrial fibrillation) that start in the upper chambers of the heart (atria). Most of these arrhythmias are benign and require no treatment. But if you’re bothered by frequent palpitations, it is best to find out exactly what’s causing them, because they’re sometimes a sign of underlying heart problems that do require treatment. Resist the urge to ignore this problem.
Unexplained decrease in performance. I didn’t include this warning sign in my original list back in 2010, but I’m adding it here because of what I’ve learned over these past few years. By decrease in performance, I’m talking about an unexplained decrease in pace, endurance, or perhaps other measures of performance. Needless to say, there could be many reasons for such a decrement, including (poor) nutrition or hydration, various illnesses or injuries, the distractions of life outside of sports, depression, or even, simply, aging. All of those potential causes deserve attention, of course. But I’ve also seen cases where an unexplained decrease in performance, in the absence of any of the other five warning signs above, was the only indication of a serious heart condition. In situations where a decrease in performance persists despite consideration of the more innocuous causes, evaluation by your doctor with a particular eye toward hidden heart problems may be in order.

I realize this is a short list. But by paying attention to just these six warning signs, athletes can uncover many of the potentially serious underlying heart-related conditions that could place them at risk. Do this for yourself and remind your athlete friends, too.

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What Can I Do to Help?

February 10, 2018 By Larry Creswell, MD 8 Comments

I get hundreds of comments here at the blog and hundreds more emails each year looking for help of all sorts. This brings both joys and challenges!

Let me head off some of the disappointment that may come when I’m not able to offer help from afar and lay out the few ways in which I might be able to help….and the many ways in which I can’t….

Ways I can help:

Provide written blog posts that help educate about issues related to heart health and athletes. I’ll try to do more writing in 2018 and I can always use suggestions for topics that may be of interest.
Provide an opportunity for readers to comment on my blog posts. I’ll approve comments that help inform my audience and I’ll approve comments that ask straightforward questions. I’ll also approve comments where one reader responds to another reader, so long as it is for the purpose of sharing experiences or useful information.
I can sometimes direct readers to other useful sources of information or support groups….but not always.
I can always suggest that you consult your doctor(s) for medical advice.
I’m happy to see new patients at my office in Jackson, Mississippi. I am an adult heart surgeon, so my wheelhouse includes problems like heart valve disease, coronary artery disease, congenital heart problems that manifest as an adult, heart failure, certain arrhythmias, aortic diseases (including dissection, aneurysm, associated bicuspid aortic valve). But I’m also happy to see “healthy” patients for the purpose of checkups and cardiac screening and to work with my cardiology colleagues to evaluate athlete patients with the whole gamut of heart problems.
I can speak to your group on issues related to heart health and athletes.
I can speak with reporters or media outlets that are interested in stories about athletes and heart health. I enjoy helping to “get the word out.”
I can associate with other medical professionals or scientific investigators who are working on projects to help better understand athletes and heart problems.
Using my blog, and also through other networking, I can share helpful resources for athletes with heart problems.

Ways I can’t help:

I can’t be your doctor from afar. And since I can’t be your doctor from afar, I can’t provide medical advice. If we haven’t met, my advice probably wouldn’t be very good, anyway. Your best source for medical advice will be your own doctor(s) who are familiar with the particulars of your situation.
I can’t help you find a doctor in your hometown….unless you live near my hometown of Jackson, Mississippi.
I don’t endorse, contribute to, or advertise charitable organizations on the basis of online contact, regardless of how worthwhile the cause may be.
I can’t connect athletes with my patients for the purpose of networking. As an alternative, though, I can sometimes direct an athlete to an online support group of athletes in similar circumstances, where helpful networking may be possible.
Except in very unusual circumstances, I don’t offer my services as an expert witness in legal proceedings.
I am not interested in opportunities for advertising at my blog.

A Preseason Check-up (Specifically for Men)

February 5, 2018 By Larry Creswell, MD 1 Comment

This is the time of year I get inquiries about pre-season medical check-up’s. I’ve written previously on this subject, including how to find a doctor in your area. I’m frequently asked, though, exactly what type of check-up is needed. Here’s my take.

Today, let me focus specifically on adult male recreational athletes. I’ll deal specifically with women in a follow-up post.

First, in terms of screening adult recreational athletes for sports-related heart risks, adult men are the group where we might expect to get the most “bang for our buck.” We know that men account for the vast majority of victims of sports-related sudden cardiac death, not only in large populations involving all types of sports, but also in very specific sports such as long-distance running and triathlon. There’s a very real reason to be looking for hidden heart disease in male athletes.

Second, in contrast to women, “healthy” men in their 20’s, 30’s, 40’s, and even 50’s are unlikely to make periodic visits to the doctor (except for injury) and very often do not have a current primary care provider (PCP). It may have been years—perhaps back to high school or college—that many men last had a complete physical exam in some context other than for a musculoskeletal injury, which typically requires a rather narrow focus. As a result, there’s often been little opportunity for discussion between adult male recreational athletes and a healthcare provider about any heart risks associated with sports participation.

Let me share how I would approach a pre-season check-up for an adult male recreational athlete who does not already have a PCP….

Although I’m a heart specialist, here I would need to put on my generalist hat to make the most of the encounter.

I would have 3 goals:

Identify any cardiovascular conditions that required further evaluation or treatment as well as any risk factors for future heart disease that could (and should) be modified;
Make an assessment of the patient’s cardiovascular risks of exercise in order to offer appropriate advice about safe forms of exercise; and
Identify any non-cardiovascular conditions that required follow-up with another doctor.

Before the Office Visit

One of the most important parts of a check-up is sharing what we call the “medical history,” an accounting of everything medically-related that’s already happened to a patient. This would include:

Past medical history (childhood illnesses, adult illnesses, surgical or other procedures)
Immunizations
Injuries
Medications and supplements
Allergies
Family history (illnesses that run in the family)
Personal and social history (smoking, drinking, sexual activity and habits, substance use/abuse, work history, travel history)
Review of symptoms (yes/no answers to a long list of questions about current symptoms).

In addition, I would also want to collect information about insurance coverage, the names and contact information for any other current and previous medical providers, and an outline of an athlete’s current exercise habits.

Depending upon the complexity of a patient’s situation, gathering all of this information could be rather time-consuming. So, in order to make the most of our available face-to-face time at the upcoming office visit, I find it helpful to collect as much of this information as possible well ahead of the office visit. I like to use 2 forms:

A general purpose medical history form such as the Health Care Consumer Questionnaire.
American Academy of Family Physicians Preparticipation Physical Evaluation forms. These forms are used ordinarily for secondary school-based screening programs, but I am fond of the first page of the History Form, which asks a series of questions (#5 through #16) related specifically to heart risk. I ask patients to complete items #1 through #51 on the first page and to discard the other pages.

When I’ve received these completed forms, I would review them and consider the possible need to gather additional information ahead of the office visit such as:

records from other physicians or hospitals
results from any heart-related diagnostic tests that may already have been completed (eg, ECG, chest x-ray, echocardiogram, Holter monitor, stress test, laboratory tests, pulmonary function tests, carotid Doppler studies, coronary calcium scoring CT scan).

Lastly, I would make a determination about any new diagnostic testing that may be helpful on the day of the office visit and schedule those tests, if any, for the morning of the office visit. If I think such testing will be helpful, I would have a telephone call with the patient ahead of the visit to explain the need for these tests.

At the Office Visit

I would plan for an office visit of approximately 45 to 60 minutes.

The first portion of the office visit is devoted to an interview. I generally spend half of the visit time on the interview. We often say that the medical history provides 80%+ of the clues to diagnosis.

First, I ask what motivated the patient for wanting the visit. There are many possible motivations. Next, we would have a chance to review the information that had already been provided about the patient’s medical history. I would take the time to clarify and better understand anything in the history that was specifically related to the heart. We would focus on those history items and on any symptoms related to exercise. I would finish by asking the patient if there were any additional, specific concerns that we should address at this visit.

The second portion of the office visit is devoted to a physical exam. Here, I would offer a complete, head-to-toe physical exam, but with special emphasis on the cardiovascular system. The exam would include:

Measurement of the height, weight, and vital signs (blood pressure, heart rate, respiratory rate, temperature)
Screening neurologic exam
Examination of the head, neck, ears, eyes, nose, and throat
Respiratory exam
Cardiovascular exam (heart, carotid arteries, abdominal aorta, arteries of the arms/legs)
Abdominal exam, including check for hernias
Genito-urinary exam
Rectal and prostate exam, in men older than 40 years
Examination of the skin

The third portion of the exam is devoted to a discussion, or wrap-up. Here, we would discuss my findings from the medical history and the physical exam and my assessment of the patient’s overall and heart health.

For the majority of patients–those who do not have any heart-related symptoms or any abnormal physical exam findings–we would spend some time discussing the utility of screening tests such as ECG, echocardiogram, laboratory testing (eg, fasting glucose, fasting serum lipid levels), or stress testing, along with the advantages, disadvantages, and potential costs. Together, we would decide if any of these tests would be helpful. There is a place for such screening tests, but only with thoughtful discussion first.

For other patients, we might identify some new heart-related condition–or at least the possibility of one. As examples, we might find that the blood pressure is elevated or note the presence of a heart murmur. In this situation, we would talk about what sort of diagnostic tests might be needed to further clarify a problem and perhaps what treatment(s) would be needed for any conditions we discovered. Needless to say, there are many potentially useful tests, depending upon the patient’s circumstances, so we won’t go into detail here. In the case of potential inherited disorders, we might need to consider evaluating other family members as well.

In either situation, if additional testing were needed we would make a plan for getting those tests completed. We would also plan for how I would share those results with the patient (eg, by telephone or during a follow-up visit). I would ordinarily make plans to visit with the patient again to discuss the results of any important testing and to resume with our wrap-up once all of the important information was at hand. If more specialized heart care were needed, I would discuss referral to the appropriate specialist (eg, general cardiologist, electrophysiologist, interventional cardiologist, specialist in congenital heart disease) and, in some cases, I would turn over the patient’s care to that specialist.

Next, we would discuss how the patient’s overall and heart health related to his/her plans for exercise and sports participation. Together, we would settle on a list of activities that would be “safe” and, likewise, settle on a list of any activities that should be avoided. We would talk about potential warning signs of heart troubles and how to be vigilant for these. If the patient required a “doctor’s letter” or some sort of pre-participation form to be completed, we would go over that form together and review its requirements. I often complete such letters or forms and return them to the patient by mail sometime after the visit.

We would then make an inventory of any other medical problems (that were not heart-related) that needed follow-up and work together to settle on an appropriate action plan. Examples of such medical problems could include: colon cancer screening in men older than 50 years, that would require a gastroenterologist visit; eyesight troubles that might best be evaluated by an ophthalmologist; periodic screening for sexually transmitted illnesses, which might best be accomplished by a primary care physician; dental care which would best be provided by a dentist; and depression, that might best be evaluated by a psychiatrist. The list of possibilities is virtually endless; this is why there can be tremendous value in having a PCP.

Before we finish the wrap-up, I would take time to have a discussion about any questions or concerns the patient brought. I usually suggest that patients bring a written set of questions that we can answer these one by one.

Finally, I would make a recommendation about when the patient should next be seen for another check-up. For “healthy” patients–those without chronic medical conditions that require monitoring–I generally suggest a check-up every 3 years for men <40 years old, every 2 years for those 40-50 years old, and every year thereafter.

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Should You Race When You’re Sick?

July 23, 2017 By Larry Creswell, MD Leave a Comment

We’ve had a fair amount of discussion here at the blog about long-term health, chronic heart conditions, and how exercise may or not be safe. We haven’t talked much, though, about acute general medical conditions, such as simply being “sick.”

Should you race when you’re sick? And, if you do….what might the consequences be?

I had a recent conversation with Chad Asplund, MD, the medical director for one of the Ironman 70.3 races, and Jon Drezner, MD, team physician for the Seattle Seahawks and an editor for the British Journal of Sports Medicine. We were talking about making a list of the concrete steps that triathletes could take to avoid serious medical problems on race day. Dr. Drezner drew my attention to a scientific report from last year that addressed this issue in long-distance running.

Let’s take a look at the study.

The Study

The team of investigators, from Cape Town, South Africa, is involved in the race-related medical care for a collection of on- and off-road running events ranging from “fun runs” to the 56-km Two Oceans Marathon, involving more than 25,000 runners each year. Over the past several years, this group has focused on studying this athlete population with an eye toward identifying, introducing, and testing interventions that might decrease the risk of race-day medical complications in participating runners. Collectively, their work has become known as the SAFER (Strategies to reduce Adverse medical events for the ExerciseR) studies. I’ve previously written here at the blog about the SAFER I study that looked at the “medical toll” of running races.

In the SAFER IV study, the investigators studied the impact of pre-race acute medical illness and do not start (DNS) and do not finish (DNF) rates for runners who competed one year in the 10-km or 22-km trail runs or the 21.1-km or 56-km Two Oceans events (1).

In the 3-5 days before each race, participants were offered the opportunity to complete an online questionnaire about any acute medical symptoms or illnesses that were present pre-race. The questionnaire included both systemic symptoms (headache, general muscle pains, cough, general joint pains, fever) and non-systemic symptoms (sore throat, runny nose, general tiredness, blocked nose, diarrhea, sore ears, abdominal pain, nausea, wheezing, bladder infection, skin rash, vomiting).

Among the participants, 7,031 runners completed the questionnaire. Any runners who reported symptoms received by email some educational material that suggested they not return to running until all symptoms were gone and they felt well again.

The Findings

A total of 19% of respondents reported at least one symptom during the pre-race period; this included 7.5% who reported systemic symptoms. The remaining 81% reported no symptoms (the control group).

In the control group, the DNS rate was 6.6%. In the symptomatic group, the DNS rate was 11.0%. Interestingly, despite the availability of the educational information for the symptomatic group (that recommended not exercising until runners felt well), 89% of those athletes started the race. For those runners who reported any systemic symptoms, the DNS rate was 15.1%.

In the control group, the DNF rate was 1.3%. In the symptomatic group who started the race, the DNF rate was 2.1% (1.6 times greater than control). For those runners who reported any systemic symptoms and who started the race, the DNF rate was 2.4% (1.9 times greater than control).

The investigators concluded: 1) symptoms of acute illness were relatively common during the pre-race period; 2) despite such symptoms and despite educational materials that discouraged participation, most athletes chose to start the race; and 3) pre-race symptoms of acute illness significantly increased the chances for a DNF.

My Take on The Study

This study is intriguing because it is the only prospective study to address the impact of pre-race acute illness on race-related performance, in any sport. First, a couple notes about the study’s limitations are in order.

First, the response rate for the pre-race survey was rather low (26.6%). The authors indicate that the respondents did not differ substantially from non-respondents in terms of demographic data, but whenever a survey response rate is low, there is a possibility of unwanted bias.

Second, no information is available on the reasons for any athlete’s DNF. Clearly, it would be more informative if pre-race symptoms could be correlated with specific race-day medical problems that might cause the athlete to DNF.

In spite of those limitations, the investigators make some important observations in their running population, but these observations can probably be generalized to other athlete populations:

Nearly 1 in 5 athletes were “sick” in the days leading up to their race. This is a lot of participants.
The vast majority of “sick” athletes probably ignored warnings about participating until they were well (although certainly some may have felt better by race day).
Pre-race “sickness” with systemic symptoms was associated with a nearly doubled risk of DNF. That’s a big effect on performance, even if finer distinctions such as finishing times could not be discerned.

Thinking about the implications, athletes and their physicians should be aware of the potential negative consequences of racing when “sick.” Race organizers should consider distributing educational information about these negative consequences, while recognizing that athletes may not accept unwanted advice not to participate. Many factors (investment in training, scheduled time off from work, costs associated with the race/travel) may be barriers in athletes’ acceptance of such advice. Lastly, additional studies would be helpful if they examined: 1) race-day medical conditions and their relationship with pre-race symptoms; and 2) other measures of performance such as actual versus expected finishing times.

Reference:

Van Tonder A, Schwellnus M, Swanevelder S, Jordaan E, Derman W, Janse van Rensburg DC. A prospective cohort study of 7031 distance runners shows that 1 in 13 report systemic symptoms of acute illness in the 8-12 day period before a race, increasing their risk of not finishing the race 1.9 times for those runners who started the race: SAFER study IV. Br J Sports Med 2016; 50:939-945.

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