Should older patients’ hearts be screened before an endurance event?
With lockdowns easing, many of our patients will be looking to get back into shape by running an endurance event, such as a 5K-run. However, with participation increasing in older age groups, we may need to consider how we can best assess and advise our patients to protect their heart health.
Endurance running demographics are changing
Despite a recent decline in running event participation, they were popular pre-pandemic with 7.9 million people taking part globally in 2018, as reported in ‘The State of Running 2019’ report.
With lockdowns easing, many of our patients may wish to get back into running and take on the challenge of an endurance event, such as the popular 5K runs or half-marathons which are being planned for the year ahead.
However, with data indicating that runners are now much older with an average age of 39 and potentially less experienced at running,, we may need to re-consider what the normal ‘athlete’ looks like in our clinics and what advice we can give them to ensure optimal heart health and safe participation.
The benefits and risks of endurance running
There are many health benefits to regular physical activity and running a marathon is very safe, with a recent literature review estimating the risk of death to be just 0.67 in 100,00 participants. However, there have also been an increasing number of studies showing an association with pre- and post-race-related cardiac dysfunction which means that training around the event may put a strain on the heart.
Sudden cardiac arrest in young competitive athletes is well characterised and is most often associated with the inherited cardiac disorder, hypertrophic cardiomyopathy. In Italy, there has been mandatory pre-participation cardiovascular evaluation for all young athletes aged 12-35 since 1982 and mortality data over a 26-year period has shown sudden cardiac arrest to have reduced by 89% in this population. This suggests that systematic pre-participation evaluation can significantly decrease mortality in young athletes.
However, these data may not extend to participants that are older with different cardiovascular risk factors and underlying medical conditions and a recent literature review found that the most common cause of death during marathons was ischaemic heart disease, which predominantly affected men over 40. It was also found that most deaths occurred in the last quarter of a marathon race.
These data would suggest that training programmes for a marathon do not put runners under the same sort of stress as they would experience on the race itself, where they would typically run for longer. The stress of running a marathon is also known to release a number of inflammatory biomarkers, creating a situation where plaque rupture and coronary thrombosis is more likely.
Further, studies have shown that race length is associated with an increased risk of cardiac arrest and death, with rates for marathons 3 to 5 times higher than for half marathons. This could be due to longer races placing greater physiological stress on participants. Men have also consistently been shown to be at greater risk than women. However, deaths from sudden cardiac arrest still do occur during half marathons and in women, so their risks should still be considered.
Should we screen our patients before an endurance event?
“The answer depends on the age and level of activity of the person. For anyone over 35, a clinical history, physical examination and an ECG would be appropriate. Although an ECG has its limitations, it may help capture some silent heart conditions. It also provides an opportunity for a doctor to assess their physical condition and give advice on training before embarking on an endurance challenge,” explains Professor Mark Mason, consultant cardiologist at Royal Brompton & Harefield Hospitals Specialist Care.
“For anyone under 35, screening would not be appropriate unless they are at risk of a heart condition, such as if they have a family history, or are experiencing signs and symptoms of one. However, if they are under 35 and an athlete regularly taking part in vigorous sporting activities, they may benefit from an intensive heart screening to rule out a silent heart condition.”
“Overall, regular exercise is beneficial and should be encouraged. As doctors, we can help advise our patients on the most appropriate level of exercise that is safe for them and participation in any endurance event, whatever its distance, should be considered with care.”
Consultant cardiologist, Medical director for Royal Brompton & Harefield hospitals
Professor Mason specialises in coronary intervention, cardiac resynchronisation therapy, and implanting pacemakers and defibrillators.