Marathon and Half marathon participation is an extreme endurance sport with intrinsic risks inherent in understanding and respecting these distances.  The absolute risk of sudden death while running the event is roughly 1 in 50,000 entries.  Current theory behind Sudden Death in these athletes, based on preliminary research and observations include:

• Underlying Conditions not previously found in the athlete.
• There is evidence that exercise can increase the risk of cardiac events, including heart attack and death. The risk is reduced by regular exercise. Attempts to exceed the intensity or duration of an established level of exercise may induce compensatory mechanisms that are deleterious.
• Endurance exercise releases muscle enzymes which may activate platelets and produce a thrombus and cardiac ischemia.
• There are studies that indicate an increased risk associated with increased caffeine consumption above 200 mg during endurance exercise.
• Sprinting the last mile may increase adrenaline and take a susceptible myocardium into an abnormal rhythm.

IMMDA (International Marathon Medical Directors Association) Guidelines on Reducing Sudden Death During Endurance Events

• Participants should not only be sufficiently trained, but equally important, they should have a goal and corresponding race plan that is appropriate for that level of training and fitness. If not, do not attempt the distance.
• Have a yearly physical examination being sure to discuss your exercise plans, goals and intensity at that visit.
• Consume one baby aspirin (81 mg) on the morning of a long run/walk of 10k or more is no medical contraindication.
• Consume less than 200 mg caffeine (2 “diner” sized cups) before and during a 10K or more.
• Only drink a sports drink or its equivalent during a workout of 10k or more.
• Drink for thirst.
• Do not consume an NSAID during a run or walk of 10k or more.
• Consume salt (if no medical contraindication) during a 10k or more.
• During the last mile, maintain your pace or slow down; do not sprint the last part of the race  unless you have practiced this in your training. Run/walk as you train.

Evaluating a runner with chest pain:

• Obtain Vital signs including pulse oximetry
• Obtain IV access
• Provide supplemental oxygen
• Review history for previous cardiac issues and for risk factors
• Obtain an EKG
• Consider given nitroglycerin and aspirin if available
• Transport to the ED via ambulance for further evaluation