"what i have in mind is a nuts and bolts checklist of the tests you need, and when, and at what age,"

bingo. this, if anything, is what can likely prevent deaths. if people know about the risk factors they carry they might make different decisions in the first place.


a quick word about prolonged QT interval. it puts folks at risk for sudden death; anytime. at rest even. not necessarily exercise related. the QT interval is a reflection of the time it takes an impulse to travel from the atria through the ventricles and in and of itself is non-specific and could reflect varying types of pathology. it just means that cardiac conduction is abnormally slow. certain drugs, for example, prolong QT.


again, we don't' know anything about the the medical histories of the victims, including what meds they might have been on. it might be difficult for families to make this decision (going forward i guess) but we need a concentrated effort from pathologists and this might shed some light on what these deaths are all about.

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jjk
http://enduranceanimal.blogspot.com/

"cardiac abnormality + adrenal surge = cardiac arrest."


i agree completely. the problem is i don't think we know for sure if it was an infarction or something else that killed these people. if we do, then i stand corrected.


but the thing is a "cardiac abnormality" is something that we should be able to screen for.

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jjk
http://enduranceanimal.blogspot.com/

My idea in these cases is that heart function outperforms the capacity of the lungs, by pumping too much blood into the pulmonary capillaries. The endurance athlete's heart is a force-feed pump capable of overwhelming the lungs.

It is well established from autopsy studies in sports-related sudden cardiac arrest (SCA) that a cardiac abnormality is found in the substantial majority of victims. As just one example, we learned earlier this year, in the largest study of SCA in long-distance running events that included 11,000,000+ participants, that cardiac abnormalities were found in more than two thirds of the victims. As Slowman noted above, in victims of sports-related SCA in younger athletes (perhaps <30 years) congenital causes predominate (eg, hypertrophic cardiomyopathy [HCM], coronary artery anomalies, long QT syndrome, etc.). In older athletes, coronary artery disease (CAD) becomes the leading cause. In the majority of instances, these cardiac conditions are unknown to the athlete and SCA is the sad, first sign that anything was wrong.

Both jjk/md and Slowman make the important observation that screening for cardiac abnormalities is one very reasonable approach that could reduce the frequency of sports-related SCA. Indeed, many of the abnormalities found at autopsy might well have been detected with careful evaluation before the athlete died. And while there remains debate about this issue in the medical community, there are certainly proponents of careful pre-participation screening, particularly for cardiac problems, in any adult who wishes to exercise or pursue an organized sporting activity of any sort. As just a couple examples, the International Marathon Medical Directors Association has recommended an annual physical examination for participants and USA Swimming requires an attestation by members annually that they are healthy before participating.

As several have postulated, there IS something special about the swim portion of a triathlon. I very much agree with the general notion that "cardiac abnormality + adrenal surge = cardiac arrest." For whatever reason, the swim portion of a triathlon may well produce the most cardiac stress--the setting in which sudden, fatal arrhythmias may develop.

All of that discussion deals with athletes taking responsibility to show up for the race HEALTHY....or at least knowing enough about their heart health to make considered judgements about the acceptability of any inherent risks of training/competing. Nobody can assume that responsibility except the athlete. And nobody has more at stake than the athlete himself. The hour spent for an annual physical examination, with a careful medical history, would be an hour (and $$) well spent.

The second "side" of this issue involves response to to the victim of SCA who is identified during the swim portion of an event. Because the chances of survival drop off quickly with each passing minute, it is critical that: 1) on-water safety personnel can identify a lifeless swimmer within seconds; 2) rescue the victim to a location where CPR can be provided; and 3) EMS or bystanders can use a defibrillator to try to restore the heartbeat. The chance of surviving is nil if any substantial time passes before CPR and defibrillation. These facts speak to the importance of a safety plan that is extraordinarily robust.

My last comment would be that it is wrong to jump to the conclusion that the frequency of triathlon-related fatalities are increasing over time. On the contrary, at January's USAT Race Directors Symposium, data were presented from the past 9 years that suggests the fatality rate has varied slightly from year to year, but HAS NOT increased recently. That said, as the sport's popularity has increased and more athletes have participated, there has been an increase in the absolute number of fatalities. It's important to remember that participation in USAT-sanctioned events has tripled in just a few years. There were approximately 4500 events and approximately 550,000 participants in 2011.

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Larry Creswell
http://www.athletesheart.org, @athletesheart

Pulmonary edema and heart failure go hand in hand. Thanks for not answering my question. The articles I have read with post mortem results have shown heart failure to be the cause of death as opposed to inhaling water. I think I've read of an embolism or two as well.

hallelujah!

thanks for that.

all of this is is still quite scary to the average middle aged guy who likes to compete and who maybe has a family history of CAD.

many of us have people depending on us to be around and we need to make sure we have all the information possible about the risks we are taking in sport before we take them.

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jjk
http://enduranceanimal.blogspot.com/

The studies on SCA in athletes all deal with land exercise. Triathlon-swim deaths are a horse of another color. Otherwise, why are we not hearing about triathletes dying in the run?

Likewise. I thought hallelujah when I read YOUR comments.

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Larry Creswell
http://www.athletesheart.org, @athletesheart

Just out of curiosity, is it not standard practice for your family doc to conduct an annual stress test once you pass a certain age? My doctor orders mine every May around my birthday for the last 5 years (big 50 next year). Compares it to my previous years and says carry on. Maybe he is generating extra revenue but it gives me a little reassurance.

Thanks for that. A little factual information instead of wild conjecture. To pedal dude: the only difference is that it's easier to give immediate aid on land than water. Did you not read his post?

what if I don't want to do a warm up swim?

You are nitpicking.

Someone having a panic attack, especially in a dangerous situation such as in the churn of the start of the race may not be together enough to remember to turn on their back, especially if they've never had one before. Hyperventilation can feel like a heart attack. It is a vicious cycle.


Panic can lead to inhalation of water, etc.


If you've never had a full blown panic attack it is hard to imagine how scary it can be in the water.

So yes, you win, it is water inhalation but it wouldn't have happened without the panic attack.

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Jen

"In order to keep a true perspective on one's importance, everyone should have a dog that worships him and a cat that will ignore him." - Dereke Bruce

I don't believe an annual physical could detect a cardiac abnormality. I have heard that in sudden death in athletes they often find arteries in the heart are going through the muscle tissue, normally the vessels run inside the fatty adipose tissue layer that covers the heart, but there is a condition where these vessels can run deeper in the muscle tissue below the fatty layer.

Seems like you and lcreswell both added logical thoughts.

As for the scary part - buy a very good life insurance policy and THEN get the doctor to check for the CAD.

How many people with cardiac abnormalities don't die during the swim? Until you know that, you really can't determine a causative relationship.

This kind of thing was shown in studies of knee injuries: most people with knee pain had certain types of damage in their knees. But then they found that a lot of people without knee pain had the same kind of damage.

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"Go yell at an M&M"

Neither EKG nor stress tests are screening tests in low risk inidividuals In fact guidelines just came out reiterating that. However if you have risk factors, high cholesterol, hypertension, diabetes... Then testing is supported.

Don't k ow your particular history, but no, I doubt this would change things. You can pass with flying colors and drop dead days later.

Sipe has held out as the most likely causative factor in these swim deaths. Now if we could just figure out who is at risk for that.....

No it is not and should not be. As someone who has worked in cardiology for a lot of years I can tell you that one of that most recent changes we have to adhere to is the applicant of appropriate use criteria tracking.
A yearly stress test in a otherwise healthy individiaul with no change in medications or symtpoms is usually not considered appropriate use for cardiac stress testing.

As far as generating revenue in health care that is a discussion for LR.

Also lots of testing leads to lots of incidental finding which may not be other findings which may not be causing any problem to the patient and now they end up with a diagnosis to follow the around that is probably of no real consequence.
Lots of testing also leads to lots of false positives, leading to more testing which holds risks may be invasive. Also stress testing has limitations in and of itself, especially in females.

sorry...

and i have had a panic attack, in fact in the water at my first ever triathlon, it was terrifying.

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jjk
http://enduranceanimal.blogspot.com/

A question about SIPE...is this something that comes on gradually or is one immediately incapacitated? If it is a gradual event and the symptoms can be recognized, then maybe some of the SIPE related deaths could be prevented if athletes were aware of those symptoms and were willing to call for help before it was too late.

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Educate yourself, Blackdog: http://www.ncbi.nlm.nih.gov/...011%3B2011%3A261404.
The lungs rarely leak blood during exercise on land.

Complicated issue. I think keeping us aware and these discussions/ideas an essential step toward reducing triathlon (swim) deaths. We cannot prevent all deaths, but a thorough approach from as many angles as possible will help. There have been many good ideas/thoughts already in these discussions. I think another important piece is for us to all look out for one another. Simple issues on land become big deals in the water. Be "gentle" in the water, be aware of your surroundings, watch for others in trouble and learn how to help (they need air/ to breath as soon as possible - ABC's airway, breathing, circulation, get rescues attention, enlists other to help). The quicker the person gets help, the better the chances of survival.
I think these athlete specific health checks are a great idea- obviously they will need to be honed over years, but we need to start somewhere. General health checks, EKG/stress tests seem prudent now and as we learn what the major contributors to these deaths are we can add/subtract/improve.
I think a paramedic/ (or doctor) (not a basic responder) should be on board a rescue boat (if one is not already) prepared to provide advanced cardiac life support as soon as the victim gets to the boat. Time is essential- every extra minute survival drops. They need to be prepared for positive pressure ventilation (intubation or at least excellent bag/valve mask) as there is good suggestion some of these deaths may be from pulmonary edema (water in the lungs). They need to be prepared for surgical airways as it has been suggested laryngeal spasm may be a factor. Paramedics can do these things and be prepared with a defribrillator and cardiac medications. Perhaps race already do this, but if not, it could help. Again we cant save everyone, but we can try.

Be safe.

Scott

Excellent question. SIPE and its symptoms (dyspnea, hemoptysis) does come on gradually. Hence, the importance of adaptation before the swim start and overloading the heart.

Does there exist a large database of "normal" EKGs in athletes of various ages? I don't think in my training I have ever ordered an EKG on an endurance athlete but I can bet it would not be "normal". What is normal at 20, 30, 40, 50, 60 years old in someone who trains 20 hours per week. Is LVH with strain "normal". Is extreme sinus arrhythmia and first degree heart block always benign? I would be fascinated to do EKGs on every participant in a given IM race and compare them to my own version of the benign tracing.

Jodi

I see what you are saying but in so many patients you need their baseline EKG to know what is normal for them.
The echo for athletic heart is not always specific either.