Risk Stratification for Coronary Artery Disease in Marathon Runners

Risk Stratification for Coronary Artery Disease in Marathon Runners

Erbel Raimund, Heusch Gerd , Möhlenkamp Stefan
European Cardiology - Volume 4 - Issue I
Published: August 2008
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Low to moderate amounts of regular physical activity reduce cardiovascular (CV) risk factor burden, improve morbidity of CV and other chronic diseases and reduce CV mortality.1–6 Aerobic endurance activities such as walking, jogging and running are popular and advocated ways to improve and maintain health across all age groups. Marathon running is an extreme form of such endurance exercise and poses a challenge to the runner and his or her CV system. Bouts of exercise may in fact increase the short-term risk of coronary events, not only in persons unaccustomed to exercise but also in joggers and marathon runners.7–12 At a younger age, i.e. <35–40 years, CV events in athletes are predominantly attributable to cardiomyopathies (40%), coronary artery anomalies including myocardial bridging (19%), left ventricular (LV) hypertrophy (8%) and myocarditis (6%).8 In those aged >35–40 years, coronary artery disease (CAD) is the most frequent cause of CV events (80%), followed by valvular heart disease (16%) and hypertrophic cardiomyopathy (3%).13

CV event rates in association with marathon running are low. However, nine deaths during running events in Germany in 2007 alone14 sustain the debate on the necessity and methods of pre-participation CV screening and risk stratification in recreational athletes. Current American Heart Association (AHA) guidelines recommend a detailed personal and family history and a physical examination for baseline screening,15 followed by further testing as appropriate, which may include exercise stress testing. European Society of Cardiology (ESC), International Olympic Committee (IOC) and German guidelines also advise routine baseline resting ECG screening.16–20 However, pre-participation screening of marathon runners is not obligatory for recreational runners in most countries, and the cardiovascular work-up of athletes contains potential pitfalls. As a prudent measure, many marathons now provide defibrillators along the course,9 but early detection of subclinical disease should clearly be the first-line approach to prevent CV events in marathon runners.

We have performed a prospective study on the prevalence of CV risk factors and coronary atherosclerosis in healthy marathon runners aged ≥50 years.21,22 The purpose of this review is to discuss our findings in light of current practice in cardiovascular risk stratification and existing guidelines on cardiovascular pre-participation screening in athletes.

The Marathon Study Cohort
The study design and initial results have been presented in detail elsewhere.21 In brief, the Marathon Study was designed to assess the prevalence of CV risk factor burden and coronary atherosclerosis in experienced marathon runners ≥50 years of age. Participants were eligible if they had no known CV disease, no symptoms of CV disease and no diabetes and had completed at least five full-distance marathon events during the previous three years. On average, they were 57±6 years old, had completed 20 marathons (median: 20; 25th/75th percentile: 14/42)and had been running marathons regularly for the past nine years (median value).22 Data were compared with controls from the Heinz Nixdorf Recall study, which was designed to determine the prognostic value of subclinical atherosclerosis compared with established risk factors in the general unselected population.23,24

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