Interesting article. They recommend better screening of participants.
In Triathlons, Swimming Poses Greatest Risk of Death
By John Gever, Senior Editor, MedPage Today
Published: April 06, 2010
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Earn CME/CE credit
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Most triathlon participants who drop dead during the competition do so in the water, researchers said.
Investigation of 14 sudden deaths among triathletes from 2006 to 2008 showed that all but one occurred during the swimming portion, reported Kevin M. Harris, MD, of the Minneapolis Heart Institute of Abbott Northwestern Hospital in Minneapolis, and colleagues.
No deaths occurred during running events. One participant died after a bicycle crash.
All the swimming deaths were officially attributed to drowning, "but seven of nine athletes with autopsy had cardiovascular abnormalities identified," the investigators wrote in a research letter appearing in the April 7 Journal of the American Medical Association.Action Points
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Explain to interested patients that triathlons typically involve strenuous exertion that may contribute to sudden cardiac death in patients not in top physical shape.
Explain that a cardiovascular stress test and other evaluations may be warranted for individuals seeking to train for or participate in triathlons for the first time.
Harris and colleagues recommended that triathlon organizers set minimum achievement standards for participants, "including swimming proficiency."
The apparent cardiovascular risk should motivate individual competitors to be evaluated before racing, but mass screening of participants is probably impractical, the researchers also noted.
The JAMA letter updates data reported by Harris at the 2009 American College of Cardiology annual meeting.
He and colleagues reviewed data on some 959,000 participants in events sanctioned by USA Triathlon, the major standard-setting organization for such events, from January 2006 through September 2008. The data were collected by this group and the U.S. Registry of Sudden Deaths in Athletes.
The 14 deaths translated to a rate of 1.5 per 100,000 participants, the researchers reported.
A total of 2,971 events were included in the analysis. Distances were relatively short in 45% of events, medium in 40%, and long in 15%.
For the swimming portions, these categories were defined as less than 750 meters for short events, from 750 to 1,500 meters for medium distances, and more than 1,500 meters for long triathlons.
Six of the swimming deaths happened in short events, four in medium-distance swims, and three in long races. Two of the latter were so-called Ironman triathlons in which the swims are 3,860 meters (2.4 miles).
Death rates per 100,000 participations in these swim distance categories were:
Short: 1.4 (95% CI 1.1 to 3.1)
Medium: 1.0 (95% CI 0.4 to 2.8)
Long: 2.8 (95% CI 1.0 to 7.5)
In eight of the fatal swimming incidents, the participants were noted to have called for help; five were found motionless in the water after other swimmers had moved on.
Although 41% of participants were female, only two of the 13 swimming deaths involved women.
Besides gender, another contributing factor was the number of competitors in a given race, according to Harris and colleagues.
The mean number of participants in triathlons in which an athlete died was 1,319 (95% CI 1,084 to 1,584), compared with 318 in races without deaths (95% CI 302 to 334), they reported.
"Because triathlons begin with chaotic, highly dense mass starts, involving up to 2,000 largely novice competitors entering the water simultaneously, there is opportunity for bodily contact and exposure to cold turbulent water," Harris and colleagues wrote.
They also noted that triathlon swimmers in distress may not attract attention as quickly as a troubled bicyclist or runner.
One large study found a death rate of 0.8 per 100,000 among marathon runners, half that in the current triathlon study.
In the seven dead swimmers with autopsy findings showing cardiovascular abnormalities, six had mild left ventricular hypertrophy. Their maximum cardiac wall thickness was 15 to 17 mm and the mean heart weight was 403 grams (SD 77). One of these individuals had a clinical history of Wolff-Parkinson-White syndrome.
The seventh athlete was found to have a congenital coronary arterial anomaly.
Harris and colleagues noted that their data may not have included every athlete who died during a triathlon, as such deaths are not subject to mandatory reporting. The study was also limited to events sanctioned by USA Triathlon, leaving out an unknown number of other competitions. Finally, some athletes likely participated in multiple events included in the study.
The Hearst Foundation supported the study.
No potential conflicts of interest were reported.
Primary source: Journal of the American Medical Association
Source reference:
Harris K, et al "Sudden death during the triathlon," JAMA 2010; 303: 1255-57.
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Related Article(s):
ACC: Triathletes More Likely to Die Suddenly Than Marathoners
A very sobering story to say the least.
I'm curious though, as to the ages of the unfortunate athletes and what their previous athletic history was prior to entering a triathlon. Were they new to the sport, seasoned participants, or somewhere in between?
Also, are participants in USAT triathlons required to make some type of statement regarding their state of health? Even if triathletes are required to provide proof of a "clean bill of health" when registering for an event, I don't see how the possibility of people dying during strenuous physical activity can be avoided.
I also wonder how comfortable these folks were in the water. When I took a SCUBA class, some mediocre swimmers were quick to panic if anything unexpected happened such as losing masks/goggles, getting kicked or other physical contact, getting water instead of air, having a muscle cramp, brushing up against plants/fishes, not being able to see the bottom. The more confident swimmers dealt with it better.
A triathlete in great cardiovascular condition can make the mistake that they don't need to train for swimming if they don't enjoy it. If they are lean and don't float and don't understand how to pace themselves on undertrained swim muscles, it would be easy to get in trouble.
my 2c
Along with those reasons to panic, add in the fear of swimming in a cold dark lake with little to no visibility underwater, and not being able to get a full breath due to the chest compression caused by a wetsuit. And all of those panic factors are happening at the same time! Typical chatter on the beach before a sprint triathlon:
"So have you been doing any swimming?"
"No, I haven't been in the water since that event we did 3 months ago."
:confused::confused::confused::confused::confused:
In the seven dead swimmers with autopsy findings showing cardiovascular abnormalities, six had mild left ventricular hypertrophy. Their maximum cardiac wall thickness was 15 to 17 mm and the mean heart weight was 403 grams (SD 77). One of these individuals had a clinical history of Wolff-Parkinson-White syndrome.
The seventh athlete was found to have a congenital coronary arterial anomaly.
The victim of a fatal heart attack at a Southern Pacific meet, several years ago, was a great athlete and experienced swimmer. This makes the case for athletes to be thoughtful about their real risks, to have a bias toward more diagnostic tests, and to be realistic and cautious as they plan preventive strategies.
Although inexperienced swimmers may be more prone to panic attacks -- particularly if they train entirely in pools -- nobody is immune. Marcia Cleveland wrote about this phenomenon and gives some good advice:
www.usms.org/.../articledisplay.php
People here like to bash triathletes as weak swimmers. Some are, but that is probably not the reason for the fatalities. Difficulties such as heart attacks are more likely to lead to fatal consequences in the open water. Plus it is the first leg of the race, often starting with a hard sprint to attempt to get clear water, sometimes on very little or no warm up.
I also wonder how comfortable these folks were in the water. When I took a SCUBA class, some mediocre swimmers were quick to panic if anything unexpected happened such as losing masks/goggles, getting kicked or other physical contact, getting water instead of air, having a muscle cramp, brushing up against plants/fishes, not being able to see the bottom. The more confident swimmers dealt with it better.
A triathlete in great cardiovascular condition can make the mistake that they don't need to train for swimming if they don't enjoy it. If they are lean and don't float and don't understand how to pace themselves on undertrained swim muscles, it would be easy to get in trouble.
my 2c
rtodd - thank you for posting that. Very thought provoking indeed, as well as sobering.
I was wondering if any such studies were conducted on open water swim events not part of a triathlon. It would be interesting to compare results.
Also, why do women have a lower death rate? The point was brought up but there was no attempt to explain why.
Also, why do women have a lower death rate? The point was brought up but there was no attempt to explain why.
I may be totally off-base, but my first thought is that there are far more men competing in triathlons than women, so based on percentage, there would be fewer women fatalities.
I may be totally off-base, but my first thought is that there are far more men competing in triathlons than women, so based on percentage, there would be fewer women fatalities.
Mortality by sex is figured for each sex separately, then the two mortality figures are compared to arrive at a statement such as "women had a lower mortality."
In first study, 41% of participants were female (I'm taking the figures from above postings), 59% were therefore male. Let's smooth it a bit and say 40% F, 60% M, or a ratio of 2:3.
Of 13 swimming deaths, 11 were in men. To achieve an equal mortality in women, ca. 7.3 would have to have died (2:3 = ca. 7.3:11). But only 2 women died, not 7.
It would not be an easy task to figure out why the death rate in women was so much lower. Certainly behavioral factors weigh in (men are faster, bigger, hurt more if they run into one, have more testosterone). Maybe the currents eased women slightly out of the fray. Or the population of women as a whole prepared better. Or Darwin smiled.
Nor am I sure any conclusions about contributions to mortality from preexisting cardiac or arterial conditions can be drawn without autopsying or imaging the *entire* population of swimmers. What if 90% of all participants had some degree of arterial plaque, or an abnormality? We probably won't ever know such things. A number of elite athletes have died suddenly, during performance, of unexpected or undiagnosed conditions.
In short, :blah:
I have a theory completely unsupported by any research or medical fact but solely by personal observation, so it's probably flat wrong but here goes.
It seems that there is some weird allure of the triathlon to the crowd that "just got fit." I hear and see over and over people who have lost a little weight and have started working-out that they "are a triathlete" and are doing triathlons. Many have never done a brick workout and certainly haven't experienced anything like the sensory overload of a tri. I don't see this much with swimming, seems most people will wait extra long to do their first meet. But, for whatever reason some folks think they lose 10 pounds, buy a bike and a suit, go to a few spin classes and they are tri ready.
Chris makes a good point about lack of warm-up. No matter how much you warm up you still have 20-30 minutes of idle time before your wave goes off. It is during this 20 minute wait that I fantasize and pray that they will cancel the run leg of the race.
