Strategies to minimize the risk for acute coronary events in long-distance races: insights from the prospective RACE Paris Registry

This editorial refers to ‘Life-threatening and major cardiac events during long-distance races: updates from the prospective RACE Paris Registry with a systematic review and meta-analysis’, by B. Gerardin et al., doi: https://doi.org/10.1093/eurheartj/ehv675 In the present issue of the Journal, we saw with great interest the article entitled ‘Life-Threatening and Major Cardiac Events during Long-Distance Races’ by B. Gerardin, JP Collet and colleagues, which reports the most recent data of the prospective RACE Paris Registry.1 The RACE Paris is a prospective registry designed to collect detailed information regarding life-threatening and major cardiovascular (CV) events and non-traumatic deaths occurring during the long-distances (marathon, half-marathon, 20 km and 16 km) races organized in area of great Paris. Although the incidence and characteristics of cardiac events in master athletes have been extensively described in the last half-century in a myriad of original investigations, reviews, and commentaries, however, the RACE Paris Registry, including a million runners, is a unique, valuable source of original data regarding incidence, aetiology and prognosis of major cardiac/fatal events in a large athlete population. The present analysis offers the clue for novel considerations relative to the safety of the long-distance races in contemporary, western societies. The first consideration concerns the rarity of the cardiac events: from more than a million participants observed over a 10-year period, authors have recorded 25 major CV events (i.e., 2.33 per 100 000 runners), corresponding to 1 major event for 42 959 runners. If we compare these results with the pioneering reports from Thompson in JAMA, 19822 or Siskovic on NEJM 1984,3 it becomes immediately evident that the incidence of CV events is substantially reduced. Different figures may be due to different study methodologies and heterogeneous population comparisons, but we believe that it is more likely the consequence of the advanced, sophisticated medical care that has been implemented in these races. At support of this view, authors report that all cases of sudden cardiac arrest (SCA) occurred in front of witnesses and 88.9% of these individuals were successfully resuscitated, with fatality rate eventually limited to only two cases (overall incidence 0.19 per 100 000 runners). In the RACE Paris Registry, teams of medical professionals with automated external defibrillators (AEDs) were stationed at regular intervals alongside the race track, in addition to on-site motorized mobile intensive care units. This capillary distribution of AEDs stations was likely responsible for the low mortality, which is halved compared with case fatalities of the meta-analysis of pooled registries from different countries previously reported.4 The obvious consideration is that the medical care implemented at Paris races was efficient to minimize the risk of major coronary events and should be kept as a model when planning the medical assistance in athletic mass events. Prompt availability of AEDs is crucial to guarantee to athletic population the chance to recover from an acute event, which may occur without premonitory symptoms, in apparently healthy individuals. We believe that Cardiology and Sport Scientific Societies should more aggressively pursue this strategic objective. Another relevant information is that major CV events were more likely to occur in the last quartile of the race or within 2 h following the end of the race. This information may help the organizing committee to plan an efficient distribution of personnel and AEDs over the race course. Finally, it was confirmed that CV events were more likely to occur in case of high air pollution, which advocates the responsibility of the organizing committee to monitor the pollution index and adapt consequently the agenda of race events. When we examine the causes for acute events during the races, we have confirmation that vast majority (61%) of cases of SCA were due to myocardial ischaemia. An acute coronary thrombosis was involved in most of these cases (6/11), while stable coronary artery atherosclerosis (without thrombosis) was responsible for a minority (2/11) of cases. From the vast literature in this area, we know that exercise-induced events are most likely to affect adult and senior athletes and are in most cases the consequence of atherosclerotic plaque disruption and coronary thrombosis. This is also the experience of the present study, where plaque disruption was the lesion triggering the majority of the events. However, myocardial ischaemia also can occur in the presence of stable calcified plaque and fixed stenosis, as ‘demand’ ischaemia, due to an imbalance between oxygen supply and consumption eventually leading a life-treating tachyarrhythmias.5,6 Indeed, we are aware that majority (in this experience about two-thirds) of athletes who experience acute ischaemia and SCA do not have pre-existing symptoms or a well-known history of atherosclerotic coronary disease. Sadly, the authors report that an electrocardiogram (ECG) and cardiac stress testing were performed prior to the index race in 11 (68.8%), with 7 (43.8%) participants presenting SCA, without abnormal results. Therefore, exercise testing confirms to be an imperfect and limited tool to detect, or even rise suspicion for underlying atherosclerotic coronary artery disease in the context of preparticipation CV screening.7 However, our contemporary diagnostic capability goes well beyond exercise ECG and, of relevance for primary prevention, is the great potential of the computed tomography coronary angiography (CTCA), which is becoming largely available and affordable in our civilized western societies. Computed tomography coronary angiography allows to define, in the individual athlete, the presence and characteristics of atherosclerotic lesions, by defining the location, extension, severity, and risk for rupture. This information is crucial to implement an efficient primary prevention, including either drugs and/or lifestyle and training changes. We believe that knowledge of the coronary artery lesions (as characterized by CTCA) is a preliminary step for a personalized intervention and treatment, making real the concept of precision medical care. In our vision, the CTCA is destined to have a main role in screening adult/senior athletes for primary prevention of cardiac adverse events. This concept is slowly entering in our clinical practice and is recognized by recent ESC recommendations.8 In conclusion, the scenario of cardiac events associated with marathon race participation is currently evolving, thanks to the efficient strategy of prompt defibrillation, responsible for a substantial decline of the mortality. Primary prevention is also changing, with a more sophisticated and individually tailored approach as clue to identify and treat the coronary lesions at risk for adverse CV events. Conflict of interest: none declared. The opinions expressed in this article are not necessarily those of the Editors of the European Journal of Preventive Cardiology or of the European Society of Cardiology.