Can pre-race aspirin prevent sudden cardiac death during marathons? The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Siegel, Arthur J., and Timothy D Noakes. 2017. “Can pre-race aspirin prevent sudden cardiac death during marathons?” British Journal of Sports Medicine 51 (22): 1579-1581. doi:10.1136/bjsports-2016-096917. http://dx.doi.org/10.1136/ bjsports-2016-096917. Published Version doi:10.1136/bjsports-2016-096917 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:35014928 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Editorial races since 2000, male sex and the mara- Can pre-race aspirin prevent sudden thon were the only significant risk factors for cardiac arrest.7 Atherosclerotic heart cardiac death during marathons? disease was the predominant underlying cause in same-aged runners in a concur- Arthur J Siegel,1,2 Timothy D Noakes3 rent Parisian registry.8 Marathon running thereby illustrates the triggering of acute myocardial infarction by strenuous exer- 1 2 As if reprising the index case of Pheidip- into the underlying cause (figure 1). cise in middle-aged males with underlying pides in 490 BC, the sudden cardiac death Although the cardiac findings in this case non-obstructive coronary atherosclerosis.9 of a 32-year-old modern-day warrior at have not been released, an acute coronary mile 20 in the 2016 London marathon event is most likely as the most common RatiONALE FOR taRGETED mandates an expedited search to prevent cause of sudden cardiac death in men PREVENTION such tragic events based on novel insights over the age of 30 years including among Supported by a 44% reduction in first acute experienced runners in that event.3–5 myocardial infarctions in healthy middle- 1 McLean Hospital, Belmont, Massachusetts, USA While the overall incidence of sudden aged men in the Physicians Health Study, 2Harvard Medical School, Boston, Massachusetts, USA 3 cardiac death during marathons is low, a randomised controlled primary preven- Department of Human Biology, University of Cape 10 Town, Cape Town, South Africa cardiac arrests occur in roughly 1 in tion trial, the International Marathon 50 000 finishers.6 Based on 59 cases Medical Directors Association (IMMDA) Correspondence to Dr. Arthur J Siegel, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA; with a mean age of 42 years in a 10-year has recommended prerace aspirin for males asiegel@ partners. org prospective registry of American road over the age of 40 years with approval by Riel H, et al. Br J Sports Med November 2017 Vol 51 No 22 1579 Editorial Box 1 Rationale for using prerace aspirin to prevent sudden cardiac death during marathons ► Aspirin reduces first acute myocardial infarctions in healthy males by 44%. ► Acute myocardial infarction is the most common cause of sudden Figure 1 Modern and ancient warriors. cardiac death in males over the age of 30 including during marathons. their physicians after considering risks such higher scores correlate inversely with event- ► Use of prerace low-dose aspirin as gastrointestinal bleeding or allergy.11 This free survival.20 This finding indicates is prudent to prevent race-related strategy is concordant with clinical guide- short-term risk for acute cardiac events asso- sudden cardiac death. lines endorsing aspirin for primary preven- ciated with atherosclerotic plaque burden, tion in persons at high cardiovascular confounding the benefit of enhanced is realistic in our view, having successfully risk, which includes middle-aged males at longevity with this lifestyle.21–23 curtailed race-related fatalities due to water increased short-term risk for acute myocar- intoxication in young females through a dial ischaemia.12 13 The case for using prerace aspirin in robust consensus process.30 31 As it is safe, IMMDA’s advisory is analogous to middle-aged males inexpensive and readily available world- that proposed for firefighters, who are at Given 285 040 US male marathoners over wide, aspirin is ready for prime time in increased risk for sudden cardiac death the age of 40 in 2015,24 IMMDA’s advi- middle-aged males as a high-risk subgroup. during emergency duties in part related to sory warrants expedited attention given a Based on a predominance of current clinical procoagulant effects as shown in athletes greater than twofold increase in race-re- evidence, this remedy, known to Hippo- after strenuous physical exercise.14–16 Atten- lated cardiac arrests since 2005.7 We crates in the time of Pheidippides, may uation of training-induced prothrombotic therefore encourage medical directors to enhance the heroic dimensions of a sport effects by aspirin in firefighters would apply follow Rio de Janeiro’s lead by informing celebrating his legacy by reducing re-enact- as well to runners based on atherothrom- entrants of IMMDA’s advisory, hoping to ments of his tragic demise. bosis as the shared pathogenic paradigm.17 In avert cardiac arrests as occurred at their last Rationale contrast to continuous prophylaxis to cover two races (personal communication, Paulo If aspirin conclusively prevents first myocar- unpredictable risk in firefighters, prerace Alfono Loriega de Menezes, MD, medical dial infarctions in healthy middle-aged use may suffice for marathoners who are at director, Rio de Janeiro marathon). otherwise low cardiovascular risk as assessed Prerace aspirin provides runners males, prerace aspirin may reduce such by 10-year Framingham measures. pre-emptively with the only pharmaco- events during marathons. Assessment of coronary artery calcifica- logical agent with a class 1A recommenda- MMDA recommendation tion, which independently predicts incident tion for pre-hospital administration in the Long-distance runners, especially men coronary heart disease and death in males event of an acute coronary syndrome. Such over the age of 40, are advised in the absence 18 aged 32 to 46 years, may be useful for strat- usage may reduce the increasing frequency of specific contraindications to take prerace ifying the utility of aspirin for marathoners of emergent post-race percutaneous coro- 19 aspirin if approved by their personal physi- with such evidence for atherosclerosis. nary angioplasties and bypass surgery, as cian after discussion of its risks and benefits. This strategy may be especially relevant for occurred after the most recent Boston and Chicago marathons.25 26 ‘Just because the Contributors Both authors contributed equally to the habitual marathoners whose paradoxically viewpoints in this editorial. cardiac risk is low, doesn’t mean it can’t be lower’, argues Amby Burfoot, Runners Competing interests None declared. World’s editor-at-large and former Boston Provenance and peer review Not commissioned; marathon champion.27 externally peer reviewed. IMMDA’s advisory enables middle-aged males to make more informed decisions regarding the cardiovascular benefits of marathon training and pre-race aspirin use for risk reduction during races (figure 2).28 The lifetime benefit of reducing risk for Open Access This is an Open Access article distributed sudden cardiac death through mara- in accordance with the Creative Commons Attribution thon training can be accomplished with Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work attenuation of its transient risk during 9 29 non-commercially, and license their derivative works on races (box 1). In lieu of a randomised different terms, provided the original work is properly controlled primary prevention trial in cited and the use is non-commercial. See: http:// marathoners, which lacks feasibility due to creativecommons. org/ licenses/ by- nc/ 4. 0/ the low frequency of index events, prospec- © Article author(s) (or their employer(s) unless tive registries can be used to assess aspirin’s otherwise stated in the text of the article) 2017. All efficacy once usage gains acceptance among rights reserved. No commercial use is permitted unless otherwise expressly granted. runners contingent on wider support by the Figure 2 Father Time running a marathon medical community. marathon, by Peter de Seve, the New Yorker, The goal of reducing sudden cardiac death 13 November 1995. in middle-aged males during marathons 1580 Riel H, et al. Br J Sports Med November 2017 Vol 51 No 22 Editorial To cite Siegel AJ, Noakes TD. Br J Sports Med of the Ongoing Physicians’ Health Study. N Engl J Med a low atherosclerotic risk profile. Circulation 2017;51:1579–1581. 1989;321:129–35. 2017:CIRCULATIONAHA.116.026964. 11 Siegel AJ. IMMDA Advisory, 2015: pre-race aspirin to 22 Aengevaeren VL, Mosterd A, Braber TL, et al. The Received 29 August 2016 prevent heart attack and/or cardiac arrest during long relationship between lifelong exercise volume and Revised 8 May 2017 distance running. Available at: http:// immda. org/ wp- coronary atherosclerosis in athletes. Circulation Accepted 16 May 2017 content/ uploads/ 2015/ 08/ Spring- 2015- Pre- raceASA. 2017:CIRCULATIONAHA.117.027834 (Originally Published Online First 19 July 2017 pdf (accessed 14 Jul 2016). published 27 Apr 2017). 23 Lee DC, Brellenthin AG, Thompson PD, et al. Running Br J Sports Med 2017;51:1579–1581. 12 Siegel AJ. Pre-race aspirin usage to prevent cardiac as a key lifestyle medicine for longevity. Prog doi:10.1136/bjsports-2016-096917 arrest in susceptible runners during marathons: is opportunity knocking? Open Heart 2015;2:e000102. Cardiovasc Dis 2017. 24 Running USA: 2016 state of the sport: U.S. road race REFERENCES 13 Siegel AJ, Bhatti NA, Wasfy JH. Reprising ramadan- related angina pectoris: a potential strategy for risk trends. http://www. runningusa. org/ state- of- sport- us- 1 Siegel AJ.