triathlon

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).

Related Posts:

Japan and Triathlon Fatalities

February 25, 2016 By Larry Creswell, MD 2 Comments

I’ve recently returned from a trip to Tokyo, Japan, where I was the guest of the Japan Triathlon Union (JTU). The occasion was their organization’s 5th Annual Forum, which this year was devoted to the issue of triathlon race safety.

I appreciate the kind invitation from Mr. Otsuka and Mr. Nakayama, the help of JTU’s Kenta Kodama with the travel arrangements, and the tremendous help with translation from Ms. Tomoko Wada. My hosts were gracious in every way. I must also thank the kind folks at USA Triathlon (USAT)–Terri Waters and Kathy Matejka, for help with gathering some updated information to present in Japan, and USAT President Barry Siff for making the necessary connections with JTU.

As readers here will know, I’ve had an interest in triathlon-related fatalities and the broader issue of sudden cardiac death among endurance athletes. I had the opportunity to lead a recent USAT effort to learn more about triathlon-related fatalities and our work resulted in a 2012 report entitled “Fatality Incidents Study.” As I’ve said before, this report is good reading for athletes and event organizers who are looking for recommendations about how to race safely and conduct events with athlete safety as a first priority.

Sadly, there were 6 triathlon-related fatalities in Japan in 2015, the most ever in a single year there. Dr. Ryoji Kasanami, the Chairman of the JTU’s Medical Committee, had become familiar with our work here in the USA and was interested in learning how our findings might help JTU with better safety planning, on the parts of both athletes and event organizers.

I gave a talk at the Forum where I outlined the USAT experience with fatalities since 2003. In large part, the information is summarized in my previous blog post, Triathlon Fatalities: 2013 in review. I was able to include some updates through the 2015 season, but the central themes were the same now as then:

There is variation in the fatality rate from year to year, with an overall fatality rate of ~1 per 70,000 participants
Most fatalities occur during the swim portion of events
Most victims are male
Fatalities are most common among middle-aged athletes
There have been no fatalities among elite (professional) athletes
Among victims, there is a wide range in athlete experience and ability
There is a small number of trauma-related fatalities, arising from bicycle crashes
Among non-traumatic fatalities, the vast majority suffered cardiac arrest at the race venue
Available autopsy information for non-traumatic fatalities has shown heart abnormalities in the majority

Dr. Kevin Harris, from the Minneapolis Heart Institute, and I will be presenting an abstract at the upcoming American College of Cardiology meeting in April in Chicago on this topic. We’ll be sharing consolidated information about 106 fatalities, including the autopsy findings from 41 of the non-traumatic fatalities. I’ll report back here at the blog with an update in April.

Dr. Kasanami shared information about the Japanese experience with 37 fatalities over the past 3 decades. There were many similarities to the experience in the USA:

Some years were “safer” than others
Most fatalities occurred during the swim portion of events
Most victims were male
Fatalities were most common among middle-aged athletes
There have been no fatalities among elite athletes
There were no fatalities in young athletes

There were also some notable differences:

There were no fatalities during the bike portion
Autopsy was seldom performed in the victims

Interestingly, the bike course is always closed to vehicular traffic during triathlons in Japan, and this might obviously have an impact on the number of crashes and trauma-related fatalities. One interesting anecdote shared by a pathologist attendee related to the finding of inner ear bleeding (hemorrhage) in 2 victims. I’m not sure about the significance of this observation.

I’m intrigued by the many similarities of the Japanese experience with race-related fatalities. I also know from preliminary discussions with officials at Triathlon Australia that the experience in Australia is similar as well. I suspect that the causes of cardiac arrest in participating athletes are common broadly, and are more dependent on simply the human condition rather than race-related factors that might be specific to one region or another (eg, race safety or technical rules, approach to medical care on site, warm-up, etc.).

I’ll mention here that the Medical Committee of the International Triathlon Union (ITU) is very interested in this issue, particularly as it relates to elite athletes. I understand that efforts are being made to implement the requirement for mandatory periodic health evaluations, including EKG screening, for youth, U23, and elite athletes who participate in ITU races, perhaps beginning in the 2017 season. This follows on the heels of the international rowing federation adopting a similar policy, gradually, during the 2014 and 2015 seasons.

I worry a little about the ITU focus on elite athletes, since the problem of race-related fatalities seems to be largely one of age-group athletes, but I hope that age-group athletes will be paying attention to any recommendations that are implemented.

Lastly, I’ll close with some photographs from the trip. Since this was my first-ever visit to Tokyo and Japan, my hosts graciously afforded me about 8 hours of free time one day for the purpose of sightseeing and I took advantage. I hope to return to Japan soon to see even more.

Update on Swimming Induced Pulmonary Edema (SIPE)

May 26, 2015 By Larry Creswell, MD 6 Comments

I saw this week that there was an important new paper on swimming induced pulmonary edema (SIPE). Richard Moon, MD, and his colleagues at Duke University published a report entitled, “Immersion Pulmonary Edema and Comorbidities: Case Series and Updated Review” in a recent edition of the sports medicine journal, Medicine & Science in Sports & Exercise (1).

SIPE is known to occur not only in recreational or competitive swimmers, but also in divers. In fact, the condition was first recognized because of breathing difficulties encountered by military divers. As triathlete and swimmer readers here will know, there are many reasons why an athlete might develop shortness of breath during an open water swim. Water conditions, water and air temperature, exertion, and anxiety all play a role. SIPE is something different, altogether, though. This is a condition that develops because of immersion in the water, in which fluid builds up in the lungs and makes breathing difficult. The condition is believed to be self-limiting; if a swimmer gets out of the water, the condition will resolve. The underlying mechanisms and risk factors are not completely understood.

I’ve written about this condition in 2 previous blog posts….SIPE and More on SIPE. These posts might be a good starting point.

The newly published report is important because it reviews the medical literature and gathers all of the pertinent information about pre-existing medical conditions, or so-called comorbidities, in victims of SIPE. Dr. Moon is probably the world’s foremost authority on the topic of SIPE, so this new report deserves our attention.

The Study

There are 2 parts to the study: 1) a look at the Duke University experience with recreational swimmers who’ve had a SIPE episode and 2) a review of the medical literature on SIPE cases, both in military and recreational divers and swimmers.

In the first part, the investigators collated information on 41 swimmers who, over the past several years, had been studied at Duke University after reporting a SIPE episode. The mean age was 50.1 +/- 10.8 years (range, 25-71 years). Complete medical history data was available for 36 of the 41 swimmers.

In the second part, the investigators collected 45 previously published articles in the medical literature that reported on 292 cases of SIPE. There were 156 recreational swimmers or divers (89 men and 67 women), with a mean age of approximately 47.8 +/- 11.3 years. There were also 136 military swimmers or divers (135 men and 1 woman), with a mean age of approximately 23.3 years (range, 18-47 years).

For each of these groups, the investigators gathered information about pre-existing medical conditions in order to determine potential risk factors for the development of SIPE, focusing on: hypertension (high blood pressure), lung disease, overweight/obesity, sleep apnea, hypothyroidism, and cardiac abnormalities).

The Results

Among the Duke University group, 9 (25%) of the 36 swimmers with available health history were completely healthy. The remaining 27 (75%) had 1 or more medical/health conditions, including:

overweight/obesity in 12
hypertension in 7
cardiac arrhythmias in 4
heart valve problem (mitral valve prolapse) in 1
reduced heart function in 2
repaired congenital heart conditions in 2
asthma in 3
COPD in 1
reactive airways disease in 1
hypothyroidism in 3
diabetes in 2
polycystic ovary syndrome in 1
obstructive sleep apnea in 2

Twelve subjects had more than one of these conditions.

In the literature review, all of the 136 military swimmers and divers were healthy; they had none of the pre-existing medical/health conditions that were surveyed. In contrast, 70 (45%) of the 156 recreational swimmers or divers had one or more significant pre-existing risk factors:

asthma in 4
enlarged heart in 2
arrhythmias in 2
coronary artery disease in 3
diabetes in 4
exercise-induced cough in 1
Elevated serum lipids in 22
hypertension (high blood pressure) in 25
thickening of the left ventricle in 9
peripheral vascular disease in 1
sleep apnea in 6

As a side note, approximately 17% of cases in the literature review reported similar previous episodes or follow-up episodes that were suggestive of SIPE, giving an important look at the potential recurrence rate. And in total, 6 fatal cases of SIPE were identified in the literature review.

My Thoughts

How can all of this collated information be useful to us?

First, it’s important to note that all of the military swimmers and divers included in the literature review were healthy. We shouldn’t overlook the possibility that even completely healthy swimmers may experience SIPE.

Second, the recurrence rate of ~17% in the literature review is probably an underestimate. No doubt, some swimmers who experienced a worrisome episode of SIPE might avoid future swimming altogether. It’s very important to remember that this condition may recur.

Third, it’s very apparent that, among recreational swimmers who experience SIPE, the prevalence of important pre-existing medical conditions is rather high, at 75% in the Duke group and 45% in the recreational swimmers in the literature review. I suspect that the Duke investigators were more thorough in their history-taking and the 75% is probably more reflective of the reality.

The investigators’ aim was to identify risk factors for SIPE. Sadly, there’s obviously no single, unifying thread here. Hypertension (high blood pressure) was the most commonly identified condition among the cases, but this accounted for only ~15% of the cases. As I mentioned at the top, the physiologic underpinnings of SIPE are not completely understood and indeed there may be more than one responsible mechanism leading to some common final pathway by which fluid accumulates in the lungs. All of the various cardiovascular abnormalities identified in the cases might conceivably play a role. There’s more to learn.

It’s worth noting that the long list of medical conditions that were identified deserve careful medical attention before participating in recreational swimming events.

Advice

I’ll reprint here my best advice to athletes and event organizers regarding SIPE. I originally included this in another blog post, but this is still my best advice!

Triathletes and open water swimmers should be aware of SIPE and the possibility that this condition can be lethal.
Symptoms of SIPE can manifest for the first time even in experienced swimmers. Symptoms may develop rapidly, be unexpected, and confuse the athlete about the cause.
The development of SIPE does not appear to be confined to cold water swims or only to victims who are wearing a wetsuit at the time.
SIPE appears to be self-limiting–that is, the symptoms will subside if the victim stops exercising and gets out of the water.
Because of #2, #3, and #4, athletes who experience breathing difficulties in the open water should treat the problem like a medical emergency and STOP swimming and SEEK immediate assistance. Because of the challenges of rescue in the open water, your life could depend on recognizing a problem early and getting out of the water. I would encourage affected athletes to get complete medical evaluation as soon as possible after an episode.
There appear to be no effects on lung function after an episode of SIPE, but repeat episodes of SIPE may occur.
Affected athletes have described a variety of strategies for preventing repeat episodes of SIPE. From athlete accounts, no single strategy appears to be universally successful.
Affected athletes should use EXTREME CAUTION in subsequent open water training and races, being hypervigilant for warning signs.
Event organizers and on-water rescue personnel should be familiar with SIPE. The safety plan should allow for athletes with breathing difficulties to be removed from the water as quickly as possible.

Reference

1. Peacher DF, Martina S, Otteni C, et al. Immersion pulmonary edema and comorbidities: Case series and updated review. Med Sci Sports Exerc 2015;47(6):1128-1134.

2. More on Swimming Induced Pulmonary Edema (SIPE)

USAT Medical Multisport Conference

May 21, 2015 By Larry Creswell, MD 2 Comments

I had the chance to be a speaker at the November, 2014 USA Triathlon (USAT) Medical Multisport Conference that was held at the Olympic Training Center in Colorado Springs. The weekend brought 2 days of talks that focused on aspects of sports medicine that were particularly relevant to triathlon and multisport.

Travis Tygart, CEO of the United States Anti-Doping Agency (USADA) was the keynote speaker. We heard about event and safety planning from a very experienced group of USAT-affiliated physicians, including W. Douglas Hiller, MD, Andrew Hunt, MD, and John M. Martinez, MD. I gave talks on some of my favorite topics: “Triathlon Fatalities,” “Endurance Sport: Is it Heart Healthy?,” and “Cardiovascular Considerations in the Aging Athlete.” We had lunch with Kathy Matejka, the USAT Event Services Director and dinner with Rob Urbach, CEO of USAT.

I met some terrific folks and I learned a lot.

It was great to visit the Olympic Training Center. I particularly enjoyed the museum area and a workout at the pool. The snow and cold weather got the best of a planned group run, though.

This year’s Conference is planned for November 5-7, 2015, again at the Olympic Training Center in Colorado Springs. This year’s keynote speaker will be Robert Laird, MD, the original and long-time medical director for the Ironman World Championship race in Kona, Hawaii. This would be a worthwhile meeting for anybody who’s involved with medical care of multisport athletes, including nurses, physicians, and allied health professionals. Information about the meeting schedule, speakers, and registration can be found at the USAT website.

I hope that you’re able to join us in November!

A Weekend in Atlantic City

July 14, 2014 By Larry Creswell, MD 2 Comments

A couple weeks ago, I had the chance to spend the weekend in Atlantic City, New Jersey for the Challenge Atlantic City triathlon. You may know that this was the inaugural edition of the race and the first iron distance triathlon by Challenge in the United States. It was a terrific event and I had a great time.

I hadn’t visited Atlantic City for about 25 years. Of course, there are new casinos now, both on and off the Boardwalk, but in many ways Atlantic City was very much like I remembered. It’s a very unique combination of nostalgic Boardwalk beach town Americana and the business of towering casino hotel developments. There’s new and old. Shiny and dull. Have and have not. The differences are very striking.

It’s an unusual setting for a long-distance triathlon. No doubt, it’s difficult to produce a 140.6-mile event in any urban setting, yet alone in the middle of the summer tourist season at a beach resort town! I give the organizers a lot of credit for getting things together.

Thanks to a kind invitation from Brad Bernadini, MD, and the race director, Robert Vigorito, I had a chance to be involved with a 2-day Sports Medicine Symposium in the days before the race. I gave talks on “Athlete’s Heart: Good and Bad” and on “Triathlon Fatalities.” The program included a variety of topics. My favorite speaker was Robert Laird, MD, the long-time medical director of the Ironman World Championship. He shared the fascinating tale of medical coverage at the event over the past 30 years. My favorite slide was of Dr. Laird, stethoscope around his neck, standing on the Kona pier watching the first Kona edition of the race, in 1981. That year, he was it. Today, the event stages a 50- to 60-bed medical tent to take care of the athletes on race day. I’ll devote my next blog post to some thoughts about medical tents at large endurance sports events. I have mixed feelings.

As for the race, I chose to do the aquabike event. This was a first. I suppose there have been instances where I haven’t finished a triathlon, stopping on the run. But this was the first time I’ve ever intentionally stopped the race at T2. And I must say that race day has a very different feel when you don’t have to run a marathon after the long swim and bike! Aquabike may be calling my name.

The swim portion of the race was deceptively challenging. Held in the “back bay,” the venue was subject to a brisk incoming tide that produced a very strong current. That, combined with a very unusual serpentine single-lap course made for a difficult swim. As an interesting surprise on race morning, the water temperature was 80 degrees, so no wetsuits were allowed. Most triathletes don’t have much opportunity to do 2.4-mile swims without a wetsuit. It was a beautiful, sunny day, though, and the temperatures were mild.

The bike leg of the race took us away from the beach, up the Atlantic City Expressway (ACE), to the town of Hammonton. There, we had two ~22-mile laps through the countryside which is apparently the U.S. capitol of blueberry farming. There was a rewarding stretch through main street Hammonton on each lap where there were hundreds of cheering spectators, balloons, inflatable archway, and an announcer. The race even provided shuttle buses for spectators who wanted to make the trip to Hammonton to watch the athletes. This was a nice touch. The ride back down the ACE to the beach was tough, into a ~15 mph headwind. For me, at any rate, the ride didn’t seem “flat and fast,” as advertised!

I hope that Challenge is successful in getting this race established. I understand there is a 5-year commitment at this point. I appreciate the alternative to the series of World Triathlon Corporation (WTC) Ironman-branded events and I appreciate the choice of a venue in Atlantic City. If you’re a triathlete, check out this race. If you’re a medical or allied health professional, check out the pre-race sports medicine symposium. And if you’re both….you can have a busy weekend next June!

Like I said, I was glad that my day was finished after the 112-mile bike ride. After a shower–and a casino buffet meal–back at the hotel, I made my way to the finish line on the Boardwalk in front of historic Boardwalk Hall. Most of the 26.2-mile run took place on the Boardwalk amongst the thousands of visitors. It was really a sight. And, as always, it was a thrill to see the athletes finishing late in the evening. In Challenge style, children or family members were allowed to join athletes in the finishing chute. The children seemed to draw the biggest cheers from the crowd.