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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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Getting a Second Opinion

February 20, 2018 By Larry Creswell, MD Leave a Comment

There can be tremendous value in getting a second opinion. I’m certain about that. At times, though, the process of getting a second opinion can cause unnecessary angst for patients and doctors, alike. It shouldn’t. Here’s my take.

What do we mean by a second opinion?

We’re talking about an additional opinion from a doctor who has not already been a part of things–somebody who did not offer the first opinion. Perhaps that’s obvious. Ordinarily, the process of getting a second opinion involves:

Gathering information (eg, records, test results) that formed the basis for the first opinion for some new doctor to review.
An in-person visit with the second doctor for the purpose of an interview and physical examination.
A discussion with this doctor, where the second opinion is shared with the patient, highlighting the similarities and differences from the first opinion.

Most commonly, we’re talking about second opinions from medical specialists or subspecialists rather than primary care physicians (PCPs).

When is a second opinion helpful?

Here are some situations where second opinions can be helpful. For each situation, I’ve included an example of an athlete-related heart problem.

When the diagnosis is uncertain. Not everything in medicine is black and white. As they say, the practice of medicine is both an art and a science. Sometimes, even when all of the relevant information has been gathered, it’s still not possible to decide with certainty as to a diagnosis. In this situation, a second opinion may help to sort out the diagnosis by bringing additional experience as well as a fresh set of eyes and ears to the problem.

An example. The condition known as hypertrophic cardiomyopathy (HCM) can be a difficult diagnosis to establish. There are known genetic mutations associated with this condition, but only a small percentage of cases can be diagnosed that way. In many cases, the diagnosis depends on the findings from echocardiography, magnetic resonance imaging (MRI), clinical features, and family history. In some athletes, there can be particular difficulty in distinguishing between an athletic heart, simply the result of exercise, and HCM. It’s easy for this diagnosis to be uncertain. In this situation, a second opinion may help to gather consensus about the diagnosis or suggest additional diagnostic testing that might be helpful.

When the treatment carries high risk, is expensive, or is logistically difficult. The diagnosis is settled and the conventional treatment involves a fair bit of risk. Often, we’re talking about a surgical procedure. In this situation, a second opinion may bring clarity to the need for treatment and confirmation that the planned treatment is appropriate.

An example. The condition known as bicuspid aortic valve (BAV) can involve regurgitation (leaking) of the aortic valve as well as enlargement of the nearby aorta to form an aortic aneurysm. When this diagnosis is established in a non-emergency setting and the patient requires replacement of the aortic valve and the nearby aorta, there are often several related, but technically different, surgical options. There are different types of prosthetic heart valves and different types of substitutes to take the place of the aorta. In each of these variations, though, the operation carries a fair bit of risk, is expensive, and can be logistically difficult, especially if operation must be pursued some distance from home. Here, a second opinion can be helpful to be certain about the diagnosis and the need for operation; provide clarity about how soon an operation should be performed; provide additional discussion about the various surgical options, with the advantages and disadvantages of each; afford an opportunity to re-address the amount of risk that comes with operation; and offer thoughts about the expected recovery timeline and return to exercise.

When there are several treatment options to choose between. After a diagnosis is established, the usual next step is to settle on a treatment. For many conditions, however, there can be several treatment options. Ordinarily, doctors like to share these possibilities with a patient and then decide together which treatment is best. This choice might depend not only on the medical specifics, but also the patient’s social, work, family, financial, cultural, or religious situation. But sometimes, even after discussion, it may not be easy to choose the best treatment. In this situation, a second opinion can sometimes be helpful to explain, from another doctor’s perspective, the treatment possibilities along with the advantages or disadvantages of each option. This doctor might well include additional or different possibilities or share the opinion that some of the previously considered possibilities may not be appropriate.

An example. One common arrhythmia problem in athletes is atrial fibrillation, or “Afib.” This is a problem that can be nagging or persistent over months or even years. Once an athlete patient has had this diagnosis established, there are often many options regarding treatment: lifestyle changes like losing weight, stopping tobacco or alcohol use, or moderating extreme exercise; medicines like aspirin, anticoagulants, or anti-arrhythmics; and procedural treatments such as arrhythmia ablation or left atrial occlusion. Moreover, a patient will find that his primary care provider (PCP) and perhaps even his cardiologist may not actually perform such ablation or left atrial occlusion procedures. In this situation, a second opinion might help to review the various treatment possibilities from another doctor’s perspective, and get another take on the advantages and disadvantages of the various treatment possibilities.

When it’s mandatory. Because of various regulatory frameworks, it’s sometimes necessary to get a second opinion before a patient can receive a particular treatment. Regulations at the local hospital level, from insurance providers, or from the federal programs like Medicare and Medicaid may all come into play in this regard.

An example. For patients with severe, symptomatic narrowing of the aortic valve (aortic stenosis), we often recommend aortic valve replacement (AVR). In recent years, a new approach for AVR, trans-catheter aortic valve replacement (TAVR), has become available for select patients. To satisfy requirements of the FDA and the Medicare program, patients must get opinions from two heart surgeons before they qualify for the TAVR procedure. In this situation, the second opinion is essentially mandatory.

When is a second opinion not helpful?

In an emergency situation. Second opinions are usually not logistically possible in an emergency situation. Here, patients must usually rely on the doctors that are tending to their emergency condition, even in the situations I’ve outlined above.
When the patient is already in the hospital. Once admitted to the hospital under the care of one or more doctors, it can be difficult to pursue a second opinion, at least in the common sense. If the condition or situation is not an emergency, sometimes it’s possible for partners of specialists to add their opinion, less formally, about a particular issue.
When two or more previous opinions are already similar. There is a diminishing return with multiple second opinions. When there is already a chorus of similar opinions, it’s likely the next opinion will also be similar. In general, it’s probably not wise to chase after the opinion you want. If you search long enough, you might find that opinion, but remember that there is usually value to consensus among the opinions you’ve received. Outlying opinions should be treated cautiously.

How to find a second opinion?

Ask your primary care provider (PCP). For patients who are fortunate to have a PCP, this may be the best source of a recommendation about how and where to seek a second opinion. Your PCP will know the local medical landscape. In many cases, he may have referred you to the specialist for your first opinion. But he will also know which doctor to suggest next, whether that’s another doctor in your community or one that’s farther away.
Ask your specialist. You can certainly ask the specialist who provided your first opinion. Some specialists will be more helpful than others when it comes to identifying a good choice for a second opinion. You may find that it’s easiest for your current specialist to suggest a partner who might also take a look at your situation.
Do some (online) research. There’s a lot of information online about specialists who you might visit for a second opinion. Perhaps there’s too much information. It can sometimes be challenging to sift through all of this information and make judgements about its quality. You may find that you will need to travel some distance to see a particular specialist. The danger here, though, is in not understanding the medical details sufficiently to select just the right doctor. And sadly, sometimes if you choose the wrong type of specialist, this may not become obvious until after you’ve invested in a visit. Another approach may be to select a large medical institution and have that institution help with finding just the right doctor to see you after they get some information from you and perhaps gather some medical records.
Word of mouth. At first, word of mouth may sound like a great way to find a doctor for a second opinion. Indeed, you may have friends or family that could suggest a doctor that they’ve seen and liked. The challenge here is that it can be difficult to find just the right doctor unless your family or friends have the exact same medical problem that you do.

Doctors get second opinions, too

Sometimes doctors obtain second opinions without their patients even knowing. This is just good practice. In this situation, the process may happen behind the scenes. Your doctor may share your particulars with a colleague to ask for help in settling on a diagnosis or settling on the best treatment. Your surgeon may ask a colleague to join him in the operating room to help decide what to do with an unexpected finding. Your pathologist may “send out” your biopsy specimen to get an additional opinion from a center of expertise. These sorts of second opinions are everyday occurrences.

When to change doctors

We should wrap up with talking about when to change doctors. So far we’ve been talking about getting additional, or second opinions. Most often, this is done with the intention of continuing to receive care from your first doctor. But what if you’d like to change doctors? There’s nothing wrong with wanting to receive your ongoing care from the doctor who gave your second opinion. That’s your decision and your doctors should understand making a change like that. I suggest that straightforward discussion with your doctors is the best way to make such a change.

Finally, let me mention two particular situations where you should consider finding a new doctor:

When you are concerned about honesty, transparency, or communication with your current doctor.
When you have reasonable concern about experience on the part of your doctor, clinic, or hospital.

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More on Triathlon Fatalities–A Scientific Report

September 18, 2017 By Larry Creswell, MD 4 Comments

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).

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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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