Cardiovascular Prevention: Editorial Comment
Cardiology
Cardiology 2024;149:252–254 Received: February 15, 2024
Accepted: February 16, 2024
DOI: 10.1159/000537993 Published online: March 19, 2024
Cardiac Risks in Long Distance Runners
Konstantinos Dean Boudoulas a Filippos Triposkiadis b Harisios Boudoulas a, c
aDivisionof Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA; bDepartment of
Cardiology, Larissa University General Hospital, Larissa, Greece; cBiomedical Research Foundation, Academy of
Athens, Athens, Greece
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Keywords glucose metabolism and lipid profile, lowering resting
Exercise · Endurance · Marathon · Sudden cardiac death heart rate, maintaining normal body weight, reducing
emotional stress, and decreasing inflammation, among
others [4, 5]. All these beneficial effects protect the heart
Pheidippides (Φειδιππίδης in Greek, Fig. 1) is the against age-related damage. Regular exercise decreases
individual who inspired the modern marathon race. He the incidence of coronary artery disease, cerebrovascular
was a messenger (professional runner and currier) that disease, venous thromboembolism, and cancer decreasing
ran from the city of Marathon to Athens (42 kilometers or all-cause mortality and cardiovascular mortality [4, 5].
26.2 miles) on September 490 BC to deliver the good news These beneficial effects can be seen with as little as 15 min
to the Athenians that the Persians were defeated in of moderate exercise a day and occur in a dose-related
Marathon. When he arrived at the Acropolis in Athens, fashion up to approximately 1 h of vigorous exercise a
Pheidippides pronounced the word “Νενικήκαμεν” (“we day, but exceeding this threshold does not provide ad-
won”) and immediately collapsed and died. A week prior, ditional benefit and potentially may be harmful [1, 6, 7].
Pheidippides was sent to Sparta (249 kilometers or 155
miles) to ask for help in the war against the Persians.
Pheidippides death was the first reported sudden death in Long Distance Running and the Heart: When Is
long distance runners. The cause of his death is unknown, Enough, Enough?
though may have been due to a cardiomyopathy (cardiac
remodeling from prolonged strenuous exercise, “ΜΗΔΕΝ AΓAΝ” (“Nothing in Excess”) – Temple of Apollo in
Delphi
i.e., Pheidippides cardiomyopathy) or an acute myocar-
dial infarction (occurring during or after strenuous ex- Strenuous endurance exercise is associated with in-
ertion) [1–3]. crease in catecholamines, heart rate, blood pressure,
cardiac output, and myocardial oxygen consumption and
a potential decrease in myocardial blood flow due to a
Beneficial Effects of Exercise decrease in diastolic time [6–8]. Volume and pressure
overload may result in an acute increase in cardiac
Routine regular exercise is highly effective in the chamber size (especially right-sided chambers). These
prevention and treatment of several diseases. It provides a changes are more pronounced in individuals with less
broad range of beneficial effects on many cardiovascular training. Strenuous exercise can also result in the accu-
risk factors including lowering blood pressure, improving mulation of free radicals and lactic acidosis. In addition,
karger@karger.com © 2024 S. Karger AG, Basel Correspondence to:
www.karger.com/crd Konstantinos Dean Boudoulas, kdboudoulas @ osumc.edu
Screening prior to running a marathon mostly focuses
on the prevention of sudden cardiac death and much less
to the long-term adverse effects of long distance running.
Sudden death occurs in approximately 1 per 100,000
marathon runners. In chronic marathon runners, myo-
cardial fibrosis occurs in 10–15% of individuals, and in a
smaller study the incidence was reported to be as high as
50% [2, 6, 7].
Laily et al. [10] in this issue of Cardiology reported the
limitations in the screening criteria by the American
College of Sports Medicine (ACSM) and the European
Society of Cardiology (ESC) prior to marathon partici-
pation. The authors evaluated 25 middle-age men
(35–50 years old) who underwent 4 months of training in
preparation to run a marathon. Using ACSM screening
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criteria, all participants qualified to participate in the
competition without any further evaluation. Using ESC
criteria, 2 of the participants were classified as “high risk”
for the competition. All participants underwent an ex-
Fig. 1. Pheidippides statue in Marathon Road, Athens, Greece.
tensive cardiovascular evaluation including a medical
history, physical examination, electrocardiogram, echo-
cardiogram, cardiac magnetic resonance, computerized
cardiac biomarkers such as cardiac troponin, creatine tomography cineangiography, cardiopulmonary exercise
kinase MB, and B-type atrial natriuretic peptides have testing, and blood tests (including lipid profile). Based on
been reported to be elevated in up to 50% of marathon this comprehensive evaluation, 3 individuals were found
runners [6, 7]. Aorta stiffening has also been reported in to have significant cardiovascular disease (aortic aneu-
marathon runners, which can further exacerbate left rysm, hypertrophic cardiomyopathy, myocardial fibrosis)
ventricular dysfunction [9]. During the recovery period, requiring restriction from endurance sports. Of those
cardiac chamber size restores to baseline and cardiac 3 high-risk individuals, only 1 was identified as high risk
biomarkers return to normal within 1 week. With this by ESC criteria and none by ACSP criteria. The authors
repetitive stretch of the cardiac chambers with training concluded that serious occult cardiovascular abnormal-
and long-distance running, chronic structural changes ities can be missed in apparently healthy middle-aged
may occur in certain individuals leading to myocardial men when ACSM and/or ESC criteria are used prior to
fibrosis, particularly in the atria, intraventricular septum, athletic competition [10].
and right ventricle; these changes can become a substrate When screening, it is important to separate profes-
for atrial (e.g., atrial fibrillation) and ventricular ar- sional from “amateur” athletes. It is also important to
rhythmias. Further, strenuous exercise over a prolonged understand that competitive athletes may not be able to
period may be associated with a higher incidence of always determine when to stop competition. Warning
coronary artery disease compared to sedentary individ- symptoms such as fatigue and chest discomfort that may
uals [2, 6, 7]. occur during competition can be difficult to distinguish
from the sensation caused by the physical activity itself or
by an underlying disease process. Further, the athlete may
Screening Individuals for Marathon Running not promptly terminate physical exertion even when the
need to do so is perceived due to the circumstances and
In 1965, twenty-five thousand runners completed a pressure of competition. This physical activity is in ad-
marathon in the USA. Since that time, the popularity of dition to the emotional stress that an athlete may ex-
endurance running has increased substantially peaking in perience during competition. Pheidippides most likely
2013 when approximately eighteen million individuals had belonged to this category and even if had felt the need to
completed a marathon in the USA [7]. As the number of stop running during the last couple of miles he could not
marathon runners increased worldwide, the need for ap- do so due to the important message he had to deliver to
propriate screening in these individuals became obvious. the Athenians.
Cardiac Risks in Endurance Runners Cardiology 2024;149:252–254 253
DOI: 10.1159/000537993
At the time of screening, the prevention of sudden events cannot be identified. National and international
cardiac death needs to be taken into consideration, but registries with long-term follow-up and use of artificial
the long-term serious adverse consequences of long intelligence may help to identify not only individuals at a
distance running cannot be ignored. Thus, the individual high risk for sudden cardiac death but those susceptible to
should be fully informed about the possible long-term adverse cardiovascular events in the future [12]. Accu-
adverse effects of repetitive long distance running. De- mulating information will assist the physician in pro-
spite these risks, there will be some individuals that will viding more rational advice to those individuals who want
choose to exercise longer and more intense than what is to participate in excessive endurance exercise in the
actually required to achieve the maximal beneficial effects future.
of exercise. The motivation for these individuals may
include improving athletic performance (the professional
athlete), enjoyment, or pure “ego,” among others [7]. On
Conflict of Interest Statement
the contrary, certain cardiac diseases should not neces-
sarily disqualify a young athlete from participating in There are no relevant conflicts of interest from the authors of
certain sports [1]. Expert assessment should guide ex- this manuscript.
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ercise participation and engagement even in intense
sports. A sports cardiology team can assist to provide
tailored advice to an individual participating in a Funding Sources
sport [11].
The authors received no funding for this study.
Concluding Remarks
Author Contributions
There is substantial evidence today that individuals
engaged in excessive endurance exercise are at an in- Konstantinos Dean Boudoulas and Harisios Boudoulas con-
creased risk for a variety of adverse cardiovascular effects tributed to the design of the work, interpretation of the data,
long term that should not be ignored. Individuals that drafting of the manuscript, critically reviewing the manuscript,
want to participate in intensive endurance activities final approval of the manuscript, and accountable for all aspects of
the work. Filippos Triposkiadis contributed to the interpretation of
should be fully informed of the possible long-term the data, critically reviewing the manuscript and adding important
consequence of these activities. At present, individuals content, final approval of the manuscript, and accountable for all
who may be at risk for future adverse cardiovascular aspects of the work.
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DOI: 10.1159/000537993
