Tragically another death during the swim phase confirmed by IM France.
Tragically another death during the swim phase confirmed by IM France.
It is always sad and tragic when these events occur.
Looking at the CDC data from a few years ago, death from CAD for people is about ~500/100,000 people. That is just a tad bit higher than 14/~100,000 participants in a USAT triathlon race. The quoted SCD rate was 1.2/100,000 which is in line with previously documented SCD rates in marathon runners. And risk always goes up with age so 60 yo males will certainly have more risk than 40 yo males. One of the reasons I felt I myself needed a coronary artery calcium score, which fortunately was very reassuring.
What is bothersome to me is that it is entirely possible that a considerable number of relatively ‘new to the sport’ people may be in this group of SCD (sudden cardiac death) which is mostly from undiagnosed CAD . How best to find and screen them…how to reassure the rest…how to make sure RD’s are maximally aware to have everything in place to give a potential victim at their race the best chance of survival…It is notable that SCD appears to be higher in triathlon than in marathon running. I now believe that coronary artery calcium scoring is the very best way to evaluate anyone over 35 for their CAD risk.
You also have to understand though, that activity is indirectly proportional to your risk of heart disease and an event like an MI or sudden death. The more active you are, the less likely you will have clinically significant heart disease and die from it. We are not talking about extremes of training right now.
I liked Dan’s article on “The Risk of Not Being a Triathlete”
https://www.slowtwitch.com/Opinion/The_Risk_Of_Not_Being_a_Triathlete_6969.html
As always, everyone should, of course, speak to their own physician more in depth about any questions or concerns that they have regarding their heart health. The internet is not where you should get medical information or make medical decisions generally.
A recap of what we have had:
‘Statins and training’
https://forum.slowtwitch.com/...st=last-6643505#last
‘Worried about my heart’
https://forum.slowtwitch.com/...tring=dtoce#p6619853
‘Heart health screening thread’
https://forum.slowtwitch.com/...st=last-7150717#last
Also, since this always comes up and people want to know what the real risk is about competing in triathlon once diagnosed with heart disease…so to be complete, I’ll throw in this one
‘Sudden death in triathlon’
https://forum.slowtwitch.com/...riathlon_P6427784-2/
Here’s a link to an article I wrote for ST a while back
What Endurance Athletes Need to Know about Heart Health
https://www.slowtwitch.com/...art_Health_7911.html
Information about coronary artery calcium scoring
https://www.acc.org/…-cardiovascular-risk
Interestingly (not sure that’s the right word in that situation), events in France due to the law in that country, can only accept participants who provide a medical certificate stating they are fit to participate. This is why there are currently no Parkruns in France.
Interestingly (not sure that’s the right word in that situation), events in France due to the law in that country, can only accept participants who provide a medical certificate stating they are fit to participate. This is why there are currently no Parkruns in France.
Is that a self declaration or a cert from a GP ?
If a GP then itself is counterproductive (but maybe typical of sometimes illogical French bureaucracy) - you aren’t fit enough to get of the couch so you can’t can a med cert to start getting off the couch on a Saturday morning to do a 5k.
The other point is whether a med cert is actually any use in managing the risk (or just a false security blanket you’d normally see being pulled around by Linus) - what tests would the med cert be based upon and are those tests any good at reliably predicting the risk of a sudden death whilst exercising. I doubt they’re getting a calcium scoring done.
Interestingly (not sure that’s the right word in that situation), events in France due to the law in that country, can only accept participants who provide a medical certificate stating they are fit to participate. This is why there are currently no Parkruns in France.
Wouldn’t such a statement be at least somewhat self serving for the athlete though, like signing off on a waiver? (have no idea what such a medical certificate would state, in france)
I’d think anyone racing would be apt to attest to their current condition being fine, otherwise wouldn’t be racing. only questioning effectiveness of such a statement.
Heart breaking, condolences to the family, very sad 
thank you dtoce for the thorough lineup of info.
French here.
Yes you need a medical certificate from a GP to race a tri in France. If you’re a national federation member, your certificate is valid for several years (4 or 5, I can’t remember). If you’re not a federation member, you pay a one-day licence when you register for the race, and you have to show a certificate that is valid for 3 months.
Those certificates are light. The GP asks you how you’re going, takes your blood pressure, check your heart pulse and have you complete 10 squats then check your pulse again. And you’re good to go. I guess it’s just a way of making sure complete beginners that would be very unfit realise the impact of a sustained physical activity and get some advice. My GP, for example, who knows me very well, signs my paper without having me in her office. BUT this year, while saying she wouldn’t deny me the paper, she asked me to have a real cardiac test at a specialty medical facility, as I am close to 50.
Interestingly (not sure that’s the right word in that situation), events in France due to the law in that country, can only accept participants who provide a medical certificate stating they are fit to participate. This is why there are currently no Parkruns in France.
Wouldn’t such a statement be at least somewhat self serving for the athlete though, like signing off on a waiver? (have no idea what such a medical certificate would state, in france)
I’d think anyone racing would be apt to attest to their current condition being fine, otherwise wouldn’t be racing. only questioning effectiveness of such a statement.
Heart breaking, condolences to the family, very sad
thank you dtoce for the thorough lineup of info.
It depends a little on the event. I did one event in France where i needed a full medical from a doctor with a signed letter confirming i was fit and well enough to undertake the event. The second required me to fill out a detailed medical history form and then submit that and a letter to my Doctor, who had to sign it to confirm the information i’d provided was accurate. They’re super strict in my experience, no letter, no place.
not sure how much credence should be given to this, when I did the Paris marathon years ago I printed off a ‘doctors note’ I made in Microsoft Word and stamped it with a random stamp I found in my office - it was accepted by a volunteer who probably didn’t even read it
.
Interestingly (not sure that’s the right word in that situation), events in France due to the law in that country, can only accept participants who provide a medical certificate stating they are fit to participate. This is why there are currently no Parkruns in France.
You only need a medical certificate for Ironman France if you buy the day licence. If you have a national triathlon licence you are exempt for the medical cert. The UK triathlon licence has no medical component - so people will be competing without a medical.
I didn’t see Chattanooga 70.3 thread here or I missed it? Anyway, Paula Findlay won and there was a guy who passed out on the bike course, had a surgery and in a critical condition. Don’t know the details but it sounded like cardiac arrest. As far as I know, he went down just by himself and there was no contact with other athletes, flat tire, mechanical or bad road condition. Anyway, it was pretty sad.
I wanted to add a bit of info about how different countries manage the issue of being fit for a triathlon event and reducing risk.
In Italy anyone attending a “competitive event” including triathlon, marathons needs a medical certificate for competitive sport which needs to be renewed yearly and is sport specific.
This includes a spirometry test and ECG before and during a short exercise (usually a stepper or a stationary bicycle).
The doctor could potentially ask for additional exams.
“Non-competitive” events (which potentially includes marathons in a separate category) have much lower requirements.
I’m not sure how much it helps in reducing risk. It definitely adds attrition for participating in sports.
If you are an international athlete participating in an event in Italy you skip the requirement simply by being a member of the relevant sport federation in your country.
Tragically another death during the swim phase confirmed by IM France.
It is always sad and tragic when these events occur.
Looking at the CDC data from a few years ago, death from CAD for people is about ~500/100,000 people. That is just a tad bit higher than 14/~100,000 participants in a USAT triathlon race. The quoted SCD rate was 1.2/100,000 which is in line with previously documented SCD rates in marathon runners. And risk always goes up with age so 60 yo males will certainly have more risk than 40 yo males. One of the reasons I felt I myself needed a coronary artery calcium score, which fortunately was very reassuring.
What is bothersome to me is that it is entirely possible that a considerable number of relatively ‘new to the sport’ people may be in this group of SCD (sudden cardiac death) which is mostly from undiagnosed CAD . How best to find and screen them…how to reassure the rest…how to make sure RD’s are maximally aware to have everything in place to give a potential victim at their race the best chance of survival…It is notable that SCD appears to be higher in triathlon than in marathon running. I now believe that coronary artery calcium scoring is the very best way to evaluate anyone over 35 for their CAD risk.
You also have to understand though, that activity is indirectly proportional to your risk of heart disease and an event like an MI or sudden death. The more active you are, the less likely you will have clinically significant heart disease and die from it. We are not talking about extremes of training right now.
I liked Dan’s article on “The Risk of Not Being a Triathlete”
https://www.slowtwitch.com/...Triathlete_6969.html
As always, everyone should, of course, speak to their own physician more in depth about any questions or concerns that they have regarding their heart health. The internet is not where you should get medical information or make medical decisions generally.
A recap of what we have had:
‘Statins and training’
https://forum.slowtwitch.com/...st=last-6643505#last
‘Worried about my heart’
https://forum.slowtwitch.com/...tring=dtoce#p6619853
‘Heart health screening thread’
https://forum.slowtwitch.com/...st=last-7150717#last
Also, since this always comes up and people want to know what the real risk is about competing in triathlon once diagnosed with heart disease…so to be complete, I’ll throw in this one
‘Sudden death in triathlon’
https://forum.slowtwitch.com/...riathlon_P6427784-2/
Here’s a link to an article I wrote for ST a while back
What Endurance Athletes Need to Know about Heart Health
https://www.slowtwitch.com/...art_Health_7911.html
Information about coronary artery calcium scoring
https://www.acc.org/…-cardiovascular-risk
Great post!
However, as a fellow cardiologist and triathlon lover/supporter,
I might question implying safety by comparing sudden death (SCD) rates in triathlons with overall epidemiology of CAD and mortality rates in marathons.
- The totality of evidence suggest triathlon carries more risk than running alone–while generally safe, it calls for participants to anticipate and adequately prepare for these risks
- Most triathlon participants are not choosing between triathlon versus being a couch potato, but rather making conscious choices between athletic activities.
- I, of all people, can only agree emphatically with good preventative medicine. Individualized cardiac risk stratification is important in general for strenuous activity, but significant atherosclerotic cardiovascular disease (ASCVD) or cardiomyopathy accounts for approximately less than half of deaths (mostly sudden) in triathlon (based on findings at autopsy in Harris et al., 2017), and I believe there are contributors to SCD specific to the triathlon race setting, which are in the swim and bike portions of the events.
THE SWIM:
- Like the unfortunate soul in the OP, the great majority of SCDs in triathlon occur at the beginning, in the swim portion of the event, unlike in marathons where most SCDs occur at the finish (and marathoners usually benefit from healthcare/ defibrillator presence at finish lines where they are needed the most).
- Adrenergic surge with suddenly swimming in cold water is a likely mechanism of SCD, they are known precipitants to SCD in ASCVD, cardiomyopathy, arrhythmias, LQTS, etc.
- Likely under-diagnosed swimming-induced pulmonary edema (SIPE), which contributes to adrenergic surge and is a treatable condition. Since SIPE can occur in up to 1-2% of swimmers, this can be an under-diagnosed cause of distress while swimming.
THE BIKE:
- SCD due to ASCVD is well-described in DTOCE’s post,
- The majority of fatalities in the bike portion of triathlons are due to trauma, which contributes to ~twice the fatalities of SCD. Riding in aero is inherently less maneuverable than being on the horns or riding on a road bike.
RISK-TARGETED MITIGATIONS:–I think Dan and Slowtwitch can never educate too much on these matters.
The huge majority of fatalities in triathlon are first, due to sudden death during the swim, then remote second, due to trauma from accidents during the bike. Everything else are very very small risks.
In addition to DTOCE’s great summary of cardiac preventative care and race director attention to safety,
Participants’ employing mitigations against key risks in triathlon can lead to substantial additional benefits. All these behaviors are especially important for men age 60 and older.
- Proper warm-up before the swim, including exposure to cold water before swimming
- Ease into the swim, especially for older males
- Understand and identify signs and symptoms of coronary heart disease and SIPE. I take sildenafil 50 mg before cold water wetsuit swims, and it has been a boon for my ocean swims (though I need to mentally focus on dead kittens before getting into the water to avoid the side effects of sildenafil ).
- Focus on cycling safety–self explanatory, but it never ceases to amaze me how unsafe some people bike in these races.
When I lived in Paris (00-01) I was still playing ultimate. For some of our tournaments, we needed membership in something (forget what) which required us to each have a medical certificates. One of our players was a doctor, he brought his pad to practice one week and wrote one for each of us. He figured, he sees us every week & knows we’re healthy. He was, in general, a stand-up guy, conscientious, family man, all that, so he wasn’t trying to help us get away with anything - but this wasn’t supposed to be a full-EKG, stress-test kind of write-up.
RIP to the racer. May their memory be a blessing.
Tragically another death during the swim phase confirmed by IM France.
RIP. Sad news.
my theory:
- In general, general population is not healthy. We have issues both mental and phisically.
- triathlete population fix exactly in age and gender with the high risk of heart problems.
- swim start (i.e. open water swimming with hundreds of people) is a moment of high stress, and many people suffer anxiety episodes during this step
I am not a doctor, but I strongly believe that it cannot be generalised because triathletes are a very mixed population (most of us come from different backgrounds) and that this problem shall not be address to physical health but also stress management.
I think that swimming is a really high “energy sink”, where you can lost all your energy in a short momment only by sprinting one minute, plus adrenalin (or whatever hormone that your brain produced in high quantities at start), then you have to manage to swim between many people, that you may think that you are not going to perform as you have trained or you are afraid about the water…
Tragically another death during the swim phase confirmed by IM France.
It is always sad and tragic when these events occur.
Looking at the CDC data from a few years ago, death from CAD for people is about ~500/100,000 people. That is just a tad bit higher than 14/~100,000 participants in a USAT triathlon race. The quoted SCD rate was 1.2/100,000 which is in line with previously documented SCD rates in marathon runners. And risk always goes up with age so 60 yo males will certainly have more risk than 40 yo males. One of the reasons I felt I myself needed a coronary artery calcium score, which fortunately was very reassuring.
What is bothersome to me is that it is entirely possible that a considerable number of relatively ‘new to the sport’ people may be in this group of SCD (sudden cardiac death) which is mostly from undiagnosed CAD . How best to find and screen them…how to reassure the rest…how to make sure RD’s are maximally aware to have everything in place to give a potential victim at their race the best chance of survival…It is notable that SCD appears to be higher in triathlon than in marathon running. I now believe that coronary artery calcium scoring is the very best way to evaluate anyone over 35 for their CAD risk.
You also have to understand though, that activity is indirectly proportional to your risk of heart disease and an event like an MI or sudden death. The more active you are, the less likely you will have clinically significant heart disease and die from it. We are not talking about extremes of training right now.
I liked Dan’s article on “The Risk of Not Being a Triathlete”
https://www.slowtwitch.com/...Triathlete_6969.html
As always, everyone should, of course, speak to their own physician more in depth about any questions or concerns that they have regarding their heart health. The internet is not where you should get medical information or make medical decisions generally.
A recap of what we have had:
‘Statins and training’
https://forum.slowtwitch.com/...st=last-6643505#last
‘Worried about my heart’
https://forum.slowtwitch.com/...tring=dtoce#p6619853
‘Heart health screening thread’
https://forum.slowtwitch.com/...st=last-7150717#last
Also, since this always comes up and people want to know what the real risk is about competing in triathlon once diagnosed with heart disease…so to be complete, I’ll throw in this one
‘Sudden death in triathlon’
https://forum.slowtwitch.com/...riathlon_P6427784-2/
Here’s a link to an article I wrote for ST a while back
What Endurance Athletes Need to Know about Heart Health
https://www.slowtwitch.com/...art_Health_7911.html
Information about coronary artery calcium scoring
https://www.acc.org/…-cardiovascular-risk
Great post!
However, as a fellow cardiologist and triathlon lover/supporter,
I might question implying safety by comparing sudden death (SCD) rates in triathlons with overall epidemiology of CAD and mortality rates in marathons.
- The totality of evidence suggest triathlon carries more risk than running alone–while generally safe, it calls for participants to anticipate and adequately prepare for these risks
- Most triathlon participants are not choosing between triathlon versus being a couch potato, but rather making conscious choices between athletic activities.
- I, of all people, can only agree emphatically with good preventative medicine. Individualized cardiac risk stratification is important in general for strenuous activity, but significant atherosclerotic cardiovascular disease (ASCVD) or cardiomyopathy accounts for approximately less than half of deaths (mostly sudden) in triathlon (based on findings at autopsy in Harris et al., 2017), and I believe there are contributors to SCD specific to the triathlon race setting, which are in the swim and bike portions of the events.
THE SWIM:
- Like the unfortunate soul in the OP, the great majority of SCDs in triathlon occur at the beginning, in the swim portion of the event, unlike in marathons where most SCDs occur at the finish (and marathoners usually benefit from healthcare/ defibrillator presence at finish lines where they are needed the most).
- Adrenergic surge with suddenly swimming in cold water is a likely mechanism of SCD, they are known precipitants to SCD in ASCVD, cardiomyopathy, arrhythmias, LQTS, etc.
- Likely under-diagnosed swimming-induced pulmonary edema (SIPE), which contributes to adrenergic surge and is a treatable condition. Since SIPE can occur in up to 1-2% of swimmers, this can be an under-diagnosed cause of distress while swimming.
THE BIKE:
- SCD due to ASCVD is well-described in DTOCE’s post,
- The majority of fatalities in the bike portion of triathlons are due to trauma, which contributes to ~twice the fatalities of SCD.
RISK-TARGETED MITIGATIONS:–I think Dan and Slowtwitch can never educate too much on these matters.
In addition to DTOCE’s great summary of cardiac preventative care and race director attention to safety,
Participants’ employing mitigations against key risks in triathlon can lead to substantial additional benefits. All these behaviors are especially important for men age 60 and older.
- Proper warm-up before the swim, including exposure to cold water before swimming
- Ease into the swim, especially for older males
- Understand and identify signs and symptoms of coronary heart disease and SIPE. I take sildenafil 50 mg before cold water wetsuit swims, and it has been a boon for my ocean swims (though I need to mentally focus on dead kittens before getting into the water to avoid the side effects of sildenafil ).
- Focus on cycling safety–self explanatory, but it never ceases to amaze me how unsafe some people bike in these races.
great post, thanks for your contribution
Tragically another death during the swim phase confirmed by IM France.
RIP. Sad news.
my theory:
- In general, general population is not healthy. We have issues both mental and phisically.
- triathlete population fix exactly in age and gender with the high risk of heart problems.
- swim start (i.e. open water swimming with hundreds of people) is a moment of high stress, and many people suffer anxiety episodes during this step
I am not a doctor, but I strongly believe that it cannot be generalised because triathletes are a very mixed population (most of us come from different backgrounds) and that this problem shall not be address to physical health but also stress management.
I think that swimming is a really high “energy sink”, where you can lost all your energy in a short momment only by sprinting one minute, plus adrenalin (or whatever hormone that your brain produced in high quantities at start), then you have to manage to swim between many people, that you may think that you are not going to perform as you have trained or you are afraid about the water…
I’ve been swimming since I was a few weeks old (mommy and me photos to prove it) and from there into swim competitions for years until I burned out. Not point that out to say how great I am, but in terms of comfort, I’m like a fish in water. I agree with your energy sink comment, cold water, etc. I have had 3 moments in my life where I definitely had to take a break in the middle of the swim and just take it super super easy as something happened in my mind that got me feeling like I needed to pull out of the race and quit.
So I can only assume for other people without as many hours of swim history as myself, it would trigger even greater stress reaction? It’s hard for me to say in my case if it was heart related. I just went back to two of the incidents I can remember, of what I can only call a panic attack (although I wasn’t outwardly “panicking” just felt so much anxiety and panic that I wanted to quit and had to relax and go slow for a couple hundred yards). I always wear a heart rate monitor and in both swims that I can remember this on, spaced years apart, my HR went from mid-low 140s to high 140s/low 150s. Not exactly a massive swing. I could definitely “see” and remember the spot where the anxiety happened using the strava map with HR overlayed. It felt like the brief heart rate increase in both cases followed after I had the anxiety attack.
So I guess I could see how if someone wasn’t as comfortable in the water, and maybe wasn’t as healthy, and they had a panic attack and their heart really spiked it could be serious trouble?
Great post, thank you!
Would you mind to share more information about treatment of SIPE if you have any? I am experiencing SIPE and it’s so terrible that I stopped entering triathlons with open water swims. I also tried sildenafil (25mg) a couple of times and it seemed to help but somehow I am afraid to consider this a long term option because if I understand it correctly it can also increase the risk of cardiovascular events.
Therefore I would be very interested to learn if there are any effective and lasting treatments for SIPE?
And if sildenafil is the only option available at the moment, is there a safe way to use it from a doctor’s perspective (dose, frequency, contraindications, etc.)? It’s clear that doctors are hesitant to give these kind of recommendations in online forums but whatever you are willing to share is highly appreciated!
Thanks! Hans
I was under the impression that recommendations had been issued to Ironman (but i suspect to a specific event rather than the brand itself) that swim warm ups should be provided / allowed, to allow for acclimatisation and reduce the risk of shock from entering cold water.
I’m still surprised when i race at events that prohibit it.
At Ironman 70.3 Staffordshire last year, there was no water warm up and the water was sufficiently cold that it took your breath away as you dived in. Sad to say, there was a death during the swim, but i never saw any follow up from it.
I was under the impression that recommendations had been issued to Ironman (but i suspect to a specific event rather than the brand itself) that swim warm ups should be provided / allowed, to allow for acclimatisation and reduce the risk of shock from entering cold water.
Fwiw, there was ample warm-up area at AIX this year, and all the time for folks that wanted to use it. There were people using that opportunity/space, but I wouldn’t say a massive amount.
The water temp, thankfully, wasn’t that cold. They said 19C/66F.
The swim format was 6 athletes every 8 seconds, self-seeded based on your estimated swim finish time (you just found a place you wanted with swim finish time posts). I found the course congestion pretty minimal, with plenty of space and I think only one person lightly brushed past me the entire swim.
Obviously, that doesn’t change anything if other aspects are at play. But in terms of optimal swims - I’d even go as far as saying this was the most relaxed triathlon swim I’ve ever done. I wouldn’t say though that there was a ton of on-swim-course boats/etc (compared to some races), but there was certainly always someone within view if you were to stop and wave.
your splits? 