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The Risk of Death in Running Road Races

Does Race Length Matter?

Jennifer A. Frere, MS; Lewis G. Maharam, MD; Steven P. Van Camp, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 32 - NO. 4 - APRIL 2004


ABSTRACT

BACKGROUND: Although the risk of death for marathon participants and for high school and college athletes has been quantified, limited data are available about the risk of death in running shorter road races.

OBJECTIVE: To determine the incidence and causes of exercise-related death in running road races and to provide information that may help identify those at risk and assist race directors with medical staffing needs.

METHODS: Investigators requested the number of finishers and the number of deaths within a 5-year period (1996 through 2000) from 62 of the largest races (according to USA Track and Field in 1999) from 10K, 12K, 15K, and half-marathon distances. Differences in the risk of death between these races and marathons were compared with a chi-square analysis.

RESULTS: Thirty-eight (61%) of the officials from the 62 races responded. Five deaths occurred among 1,636,720 finishers. All the fatalities were men, and their age range was wide (38 to 84 years). Most of the deaths were in 10K races (4 deaths); 1 was in a half-marathon race. Further data were available on 3 of the runners, whose deaths were attributed to coronary artery disease. The overall incidence of death in running road races was approximately 3.1 per 1 million finishers. This risk and that for 10K races are significantly lower than the risk reported for marathons from combined data from other sources.

CONCLUSION: The risk of death in running road races is significantly lower than the risk for marathons. These data may help to identify participants at risk and assist race directors in determining medical staffing needs on race day.

The tragedy of exercise-related death is fortunately a rare occurrence that may strike young, asymptomatic, and seemingly healthy athletes. Well-known examples include the deaths of basketball players Hank Gathers and Reggie Lewis and, more recently, Minnesota Vikings tackle Korey Stringer. Such incidents have increased the awareness of exercise-related death, raised questions about proper preparticipation screening for athletes, and prompted studies into the incidence and causes of exercise-related death.

The risk of exercise-related death has previously been quantified for high school and college athletes.1 In a study of the risk of death in marathons, Maron et al2 estimated that 1 death would occur in 50,000 marathon finishers, while Tunstall Pedoe3 reported 1 death in 88,000 for finishers of marathons and half marathons in Britain. Limited data, however, are available on runners in road races from the 10K to half marathon distances.

Road races are popular events that attract runners of widely disparate ages, athletic ability, experience, and training levels. Participation in these events has grown over the years. As road races draw more participants—including older runners likely at increased risk of exercise-related problems, including death—defining the risk of death in these events would be useful. Such information may help race participants and their physicians in decisions regarding participation. A better understanding of race deaths could also provide the basis for improved evaluation and medical treatment of runners and assist race directors, especially those of larger races, in their decisions about medical staffing.

Methods

Data collection. Road races targeted for data collection were identified from the New Expanded Data on Largest Races and Festivals, a list of races published by USA Track & Field Road Racing Information Center (USATF RRIC).4 Race directors of the 20 largest 10K races, the 10 largest 12Ks, the 12 largest 15Ks, and the 20 largest half marathons were sent questionnaires regarding their races from 1996 through 2000. To facilitate questionnaire completion and encourage response, only information crucial to the study (numbers of entrants, finishers, and deaths) was initially requested from race directors. If the actual numbers of entrants and finishers were not available over the 5-year period, race directors were instructed to provide minimum estimates of the number of entrants. Race directors who did not respond were sent a second questionnaire. To reach race directors who did not respond to the second questionnaire, investigators attempted to contact them by telephone.

Definitions, calculations, and statistical analysis. We defined death as that occurring in runners who had symptom onset during or within 1 hour of participation in a road race. Deaths included cardiovascular fatalities (cardiac arrest, myocardial infarction, and cardiac arrest initially resuscitated with subsequent death from cardiac arrest) as well as fatalities from noncardiovascular causes (hyperthermia, hyponatremia, asthma, trauma, or other road race-related problems).

Race directors reporting a death were subsequently contacted for further information regarding the fatality, including circumstances surrounding the death. Demographic, clinical, and pathologic information were requested from the county medical examiner or coroner. When information regarding the death was not available from the race directors, investigators contacted the local newspapers and searched the Internet for information.

The risks of death for each distance and in combined distances were calculated by dividing the number of deaths by the number of race finishers. The number of finishers was used, because this information was more frequently reported by the race directors. Using the number of finishers also facilitated comparison with other studies that used finishers in their calculations.2,3 According to the USATF RRIC, approximately 80% to 85% of road race entrants finish the race event,4,5 although this estimate did not specify whether it applied to all race distances. Thus, for the few races that provided only the number of entrants rather than finishers, the number of finishers was estimated to be 80% of the number of entrants. The risks of death were also calculated for the number of deaths per 1 million finishers in all races and of each distance.

Chi-square analysis was used to compare the risks of death in the road races with the overall risk previously calculated for marathons by Maron et al,4-6 Tunstall Pedoe,3 and also the other road race distances.

Of the 62 race directors contacted, 23 (37%) responded to the first questionnaire. Seven race directors responded to the second request for information, and 8 more responded to a phone call or e-mail, making the final response rate 61% (38 of 62). The final response rates for each distance were 75% for the 10K races, 20% for the 12Ks, 75% for the 15Ks, and 60% for the half marathons.

Results

Deaths. Race directors reported 5 deaths in a combined 1,636,720 finishers, making the overall risk of death 1 in 327,344 finishers (0.0003%), or 3.1 deaths per million finishers (table 1). Chi-square analysis with data from 655,000 marathon finishers2,3 showed that deaths observed in the 10K races and in the combined road race distances were significantly lower than expected (table 2). However, if only 2 more deaths had occurred in the 10K races, significance would be lost for this comparison. No significant difference was found in the risk of death in the 12K, 15K, and half marathon, although this finding may be due to the relatively small number of finishers in these races. No significant differences were found in chi-square analyses between the individual race distances (data not shown).

TABLE 1. Incidence and Risk of Death in Road Races, 1996-2000

Road Race
Distance (No. of Races)
DeathsFinishersIncidenceDeaths per
Million Finishers
10K (15)
12K (2)
15K (9)
Half marathon (12)
4
0
0
1
931,766
251,421
168,028
285,505
1/232,942
0
0
1/285,505
4.3
0
0
3.5
Totals (38)51,636,7201/327,3443.1

K = 1,000 m

TABLE 2. Chi-Square Comparisons of Risk of Death in Road Races and Marathons

Race DistanceObserved
No. of Deaths
Expected
No. of Deaths*
10K
12K
15K
Half marathon
4†
0
0
1
13.0
3.5
2.4
4.0
Total5†22.9

*Expected number of deaths is based on the number of deaths calculated for marathons from combined data (9 deaths in 655,000 finishers)2,3 and the total number of finishers in each race distance. The number of deaths expected is the number expected at the different race distances (and the total for all races) if the risk of death in marathons and the shorter road races were the same.

† Statistically significant, P <0.05

Causes of death. A total of 5 fatalities was reported among 1,636,720 finishers of all race distances. All 5 deaths were men (age range, 38 to 84 years). Information about the cause of death was available for 3 runners (table 3). Each of these 3 deaths was attributed to coronary artery disease (CAD), and only the age and sex were known for the remaining 2 deaths.

TABLE 3. Clinical Profile of Road Race Fatalities, 1996-2000

Case No.   Age (yr)  Sex  Race
Distance
  
Cause of  
Death
Source of
Information
  
Comments  
138M10KCADAutopsy
report
Heart weighed 410 g; at least 50%
left main artery stenosis; 99% stenosis
of proximal left anterior descending
artery; 50% stenosis of left circumflex
artery; "pinpoint, nearly complete
stenotic" right coronary artery
253M10KCADMedical
examiner's
case summary
NA
384M10KCADNewspaper
report
NA
449M10KNARace reportAge and exertion make CAD a
likely cause
542MHalf
marathon
NARace reportAge and exertion make CAD a
likely cause
M = male; CAD = coronary artery disease; NA = information not available

Incomplete responses. We examined to what extent the number of finishers in responding races represented the full population of runners who finished in all the races that were initially contacted. Combined data from USATF RRIC in 1999 and 2000 (the last 2 years studied and the only years such information was available) were analyzed (table 4). Finishers in responding races constituted approximately 72% of the total finishers among all races we solicited. The finishers in the responding 10Ks accounted for approximately 89% of the finishers in 1999 and 2000 of all 20 10K races; for the 15Ks, 77% of all finishers, and for the half marathons, 69% of all finishers. Although only 2 of 10 12K races solicited responded, these races had approximately 40% of the estimated number of finishers for the largest 10 races in this distance in 1999 and 2000.4-6

TABLE 4. Race Finishers in All Races and Finishers in Responding Races (1999 and 2000)*

Distance  Finishers in All
Races Contacted
(No. of Races)
Finishers From
Responding Races
(No. of Races)
  
Finishers From
Responding Races
(%)
10K
12K
15K
Half marathon
Totals
414,508 (20)
238,501 (10)
78,092 (12)
184,927 (20)
916,028 (62)
370,120 (15)
95,979 (2)
60,043 (9)
127,431 (12)
653,573 (38)
89
40
77
69
72
*These were the only years such data were available.

Discussion

This study is the first that we know of to provide information on exercise-related deaths in popular road race distances.

Deaths and race distances. The risk of sudden death in this study (3.1 deaths per million finishers) is significantly lower than the overall risk for marathons (14 per million) calculated from combined data (9 deaths in 655,000 marathon finishers).2,3 We found no significant difference in the risk of death between the road race distances; however, the relatively small number of finishers in the 12K, 15K, and half-marathon distances compromises comparisons between these races of different distances.

Reasons for the lower risk of death in the road races in our study are speculative but include the following: (1) these shorter races (relative to marathons) translate into less time that participants are at risk, (2) shorter races may not be run at as high an intensity, since many runners are participating recreationally, and (3) evaluation of marathon finishers underestimates the total number of runners, thereby overestimating the actual risk to the participants. Thus, if a higher percentage of runners drop out of marathons than the races we studied, the risk for marathon runners would represent an overestimate, and the risk of death in shorter races may therefore not actually be significantly lower.

Cause of race deaths. The cause of death in road races in this study appears to be primarily CAD, the cause also seen in the marathon studies.2,3 The three deaths for which information was available were from CAD, and the circumstances (during a road race) and limited data (elevated risk based on age) on the other two deaths also appear to be consistent with this as a cause. Three of the four deaths in the study by Maron et al2 were also from CAD (the fourth was due to a congenital coronary artery anomaly in a 19-year-old woman), and in Tunstall Pedoe's study,3 9 of the 10 cardiac events (5 deaths and 5 cardiac resuscitations) were attributed to CAD. These data are consistent with studies in which severe CAD is the most common cause of sudden cardiac death in individuals older than age 30,7,8 the predominant age-group of most runners in these events. In contrast, the cause of sudden cardiac death in high school and college athletes is typically significant structural, nonatherosclerotic, cardiovascular disease (eg, hypertrophic cardiomyopathy, congenital coronary artery anomalies).1,9

In our study and the two marathon studies, deaths from hyponatremia were not reported, although this condition was reported as the cause of death in a 26-year-old woman participating in the 2002 Boston marathon.10 Exercise-associated hyponatremia, a condition that is more common in women than in men, is more likely to occur during longer runs (marathons), since participants at risk appear to be those in running events lasting more than 4 hours.11

Study limitations. Although the respondents' races composed more than 70% of finishers in 1999 and 2000, this study required race directors to volunteer information. Therefore, data from some races was not available, although most of these races were the smaller ones in each category. If deaths did occur in races whose directors did not respond, then our overall risk of death may be an underestimate. However, this finding represents an issue we are unable to address any further. The incomplete data from postmortem reports on four of the runners (cases 2 through 5) also limit the ability to make accurate comparisons of cause of death between race distances.

Directions for future research. A prospective study of races might resolve some of the problems of gathering complete and accurate information in retrospective studies. Future research could track participating races annually for information on the number of finishers and deaths. The apparent difference in risk of death for men compared with that of women could be investigated if the numbers of male and female finishers were recorded. Data on the risk of nonfatal cardiac events, such as myocardial infarctions and successfully resuscitated cardiac arrest, could also be studied. Complete demographic and clinical findings on deaths from postmortem reports would provide more information on the causes of death, leading to a more accurate profile of the person at-risk.

Study Implications

This study examines the risk of death in road races of varying distances and supports the perspective that running road races is safe, having a significantly lower fatality rate compared with marathons. While the risk of death during running road races is small, learning the primary causes of deaths associated with participation may help identify those at risk. A better understanding of exercise-related death may help physicians and their patients decide whether or not participation in a road race is appropriate. Data from this study may also assist race directors and medical directors, particularly of large races, in their emergency medical preparations.

We are indebted to Patricia Patterson, PhD, for assistance with the statistical analyses and Michael J. Buono, PhD, for presubmission manuscript review, both of San Diego State University.

References

  1. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27(5):641-647
  2. Maron BJ, Poliac LC, Roberts WO: Risk for sudden cardiac death associated with marathon running. J Am Coll Cardiol 1996;28(2):428-431
  3. Tunstall Pedoe D: Sudden cardiac death in sport—spectre or preventable risk? Br J Sports Med 2000;34(2):137-140
  4. USA Track & Field Road Racing Information Center: Largest running events by distance—US 1999. Available at https://www.runningusa.org/cgi/evbg-dst.pl. Accessed December 22, 2003
  5. USA Track & Field: On the Roads. 1999;13(summer):1-12
  6. USA Track & Field Road Racing Information Center: Largest running events by distance—US 2000. Available at https://www.runningusa.org/cgi/evbg-dst.pl. Accessed December 22, 2003
  7. Waller BF, Roberts WC: Sudden death while running in conditioned runners aged 40 years or over. Am J Cardiol 1980;45(6):1292-1300
  8. Thompson PD, Funk EJ, Carleton RA, et al: Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA 1982;247(18):2535-2538
  9. Van Camp SP: Exercise-related sudden death: risks and causes (part 1 of 2). Phys Sportsmed 1988;16(5):97-112
  10. Arnold D: To the end, marathon was at center of student's life. Boston Globe April 18, 2002, p A1. Available at https://nl.newsbank.com. Accessed December 22, 2003
  11. Davis DP, Videen JS, Marino A, et al: Exercise-associated hyponatremia in marathon runners: a two-year experience. J Emerg Med 2001;21(1):47-57


Mrs Frere is a biology and physiology teacher at Helix Charter High School in La Mesa, California, and completed this work while a graduate student in the department of exercise and nutritional sciences at San Diego State University. Dr Maharam is the medical director of the New York Road Runners and ING New York City Marathon and is chairman of the board of governors of the International Marathon Medical Directors Association in New York City. Dr Van Camp is a cardiologist with the Alvarado Medical Group in San Diego, California. Address correspondence to Steven P. Van Camp, MD, 6386 Alvarado Ct, Suite 210, San Diego, CA 92120; e-mail to [email protected].

Disclosure information: Ms Frere and Drs Maharam and Van Camp disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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