119
Atherosclerosis, 27 (1977) 119-120 @ Elsevier/North-Holland Scientific Publishers,
Letter
Ltd
to the Editors
MARATHON RUNNING ATHEROSCLEROSIS
AND IMMUNITY
TO CORONARY
Editors. To support his view that marathon running prevents the progression of, or reverses, the process of atherosclerosis, Bassler [l], in a letter to the Journal, refers to a previous communication by us [ 21. Because the relevant parts of our paper were not quoted in full, our intended meaning has been distorted. Our previous letter pointed out that, despite the widely proclaimed “cardiovascular mystique [3] of marathon runners, we have encountered active marathon runners with myocardial infarction. In addition, in a select group of active South African ultralong-distance runners, four cases of sudden death have occurred, but as we reported - “Post-mortem data on the cases of sudden death were inadequate so that Dr. Bassler’s and Dr. Staff’s statement that no cases of death due to coronary atherosclerosis have been recorded in marathon finishers remain unchallenged, although we are unconvinced that a sufficiently large percentage of hearts of marathon runners who die are adequately examined from the pathological point of view. Even if the corollary that marathon runners are immune to atherosclerosis is correct, they are not immune (as our data show) to either myocardial infarction, or apparently, to myocardial ischaemia in the presence of normal coronary arteries”. Since publication of that letter, a case of fatal coronary atherosclerosis occurring in a veteran long-distance runner has been reported in a lay athletic journal by a doctor, herself a champion marathon runner [4]. Although technically not a marathon runner by Bassler’s criteria, this particular athlete had completed a 23 mile training run the day before his death; he had been running regularly since his teens, he was a non-smoker and within the year before his death he had won the National Amateur Athletics Union Masters 25 kilometer race. In addition, our series of active marathon runners who have developed myocardial infarction now totals six. Coronary angiography performed in four of these athletes has shown coronary artery disease that was considered angiographically indistinguishable from coronary atherosclerosis [ 51. Bassler’s estimation that “five years or 10,000 miles of endurance running will result in improved angiograms” is pure speculation. Two of our athletes have greatly exceeded these supposed limits, yet both have significant coronary artery disease. One athlete, a 46-year old non-smoker with normal blood lipids, has been involved in strenuous endurance exercise, since childhood as a swimmer, later as an international class oarsman before turning to long distance running at the age of 30. Despite completing 14 consecutive Comrades Marathons (each of 56 miles) and running more than 30,000 miles in training, he has
120
triple vessel disease as shown angiographically. We continue to be uncertain about Bassler’s epidemiological studies. Neither his communication at the recent Marathon Conference in New York, nor the statement by Cardello [6] that “until a single case of fatal coronary atherosclerosis is reported in a marathon finisher there will be few data to study” make it entirely clear just how many hearts of marathon runners have in fact been satisfactorily autopsied. In addition, any study purporting to establish the incidence of coronary atherosclerosis amongst marathon runners that considers only data on sudden deaths has a serious epidemiological flaw [7], because coronary atherosclerosis may present in a variety of clinical syndromes, of which sudden death is only one. Until firm data have been published to show that marathon running can prevent or reverse the process of coronary atherosclerosis, we join Dayton [8] in calling for a moratorium on these assertions. 1 Bassler, T.J., Is atheroma a reversible lesion? Atherosclerosis, 25 (1976) 141. 2 Noakes, T.D. and Opie, L.H., Marathon runners and impending heart-attacks, Lancet, 1 (1976) 1020. 3 Green. L.H., Cohen, S.I. and Kurland, G., Fatal myocardial infarction in marathon racing, Ann. Intern. Med., 84 (1976) 704. 4 Ullyot, J., The Medical Report. Runners World, 11 (September 1976) 16. 5 Noakes, T.D., Opie. L.H., Beck, W., McKechnie, J.W., Benchimol. A. and Desser. K., Coronary heart disease in marathon runners. Paper read at the New York Academy of Sciences Conference on the Marathon, New York City, October 1976. 6 Cardello, F., Marathon vs distance running, New Engl. J. Med., 294 (1976) 115. 7 Morris, J.N., (Ed.), Uses of Epidemiology, Churchill-Livingstone, Edinburgh, London, New York, 1975. PP. 121-141. 8 Dayton, S.. Long distance running and sudden death, New Engl. J. Med., 293 (1975) 941.
MRC Heart Disease Research Unit, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town (South Africa) (Received (Accepted
14 January, 18 January,
1977) 1977)
T.D. NOAKES L.H. OPIE
Atherosclerosis, 27 (1977) 119-120 @ Elsevier/North-Holland Scientific Publishers,
Letter
Ltd
to the Editors
MARATHON RUNNING ATHEROSCLEROSIS
AND IMMUNITY
TO CORONARY
Editors. To support his view that marathon running prevents the progression of, or reverses, the process of atherosclerosis, Bassler [l], in a letter to the Journal, refers to a previous communication by us [ 21. Because the relevant parts of our paper were not quoted in full, our intended meaning has been distorted. Our previous letter pointed out that, despite the widely proclaimed “cardiovascular mystique [3] of marathon runners, we have encountered active marathon runners with myocardial infarction. In addition, in a select group of active South African ultralong-distance runners, four cases of sudden death have occurred, but as we reported - “Post-mortem data on the cases of sudden death were inadequate so that Dr. Bassler’s and Dr. Staff’s statement that no cases of death due to coronary atherosclerosis have been recorded in marathon finishers remain unchallenged, although we are unconvinced that a sufficiently large percentage of hearts of marathon runners who die are adequately examined from the pathological point of view. Even if the corollary that marathon runners are immune to atherosclerosis is correct, they are not immune (as our data show) to either myocardial infarction, or apparently, to myocardial ischaemia in the presence of normal coronary arteries”. Since publication of that letter, a case of fatal coronary atherosclerosis occurring in a veteran long-distance runner has been reported in a lay athletic journal by a doctor, herself a champion marathon runner [4]. Although technically not a marathon runner by Bassler’s criteria, this particular athlete had completed a 23 mile training run the day before his death; he had been running regularly since his teens, he was a non-smoker and within the year before his death he had won the National Amateur Athletics Union Masters 25 kilometer race. In addition, our series of active marathon runners who have developed myocardial infarction now totals six. Coronary angiography performed in four of these athletes has shown coronary artery disease that was considered angiographically indistinguishable from coronary atherosclerosis [ 51. Bassler’s estimation that “five years or 10,000 miles of endurance running will result in improved angiograms” is pure speculation. Two of our athletes have greatly exceeded these supposed limits, yet both have significant coronary artery disease. One athlete, a 46-year old non-smoker with normal blood lipids, has been involved in strenuous endurance exercise, since childhood as a swimmer, later as an international class oarsman before turning to long distance running at the age of 30. Despite completing 14 consecutive Comrades Marathons (each of 56 miles) and running more than 30,000 miles in training, he has
120
triple vessel disease as shown angiographically. We continue to be uncertain about Bassler’s epidemiological studies. Neither his communication at the recent Marathon Conference in New York, nor the statement by Cardello [6] that “until a single case of fatal coronary atherosclerosis is reported in a marathon finisher there will be few data to study” make it entirely clear just how many hearts of marathon runners have in fact been satisfactorily autopsied. In addition, any study purporting to establish the incidence of coronary atherosclerosis amongst marathon runners that considers only data on sudden deaths has a serious epidemiological flaw [7], because coronary atherosclerosis may present in a variety of clinical syndromes, of which sudden death is only one. Until firm data have been published to show that marathon running can prevent or reverse the process of coronary atherosclerosis, we join Dayton [8] in calling for a moratorium on these assertions. 1 Bassler, T.J., Is atheroma a reversible lesion? Atherosclerosis, 25 (1976) 141. 2 Noakes, T.D. and Opie, L.H., Marathon runners and impending heart-attacks, Lancet, 1 (1976) 1020. 3 Green. L.H., Cohen, S.I. and Kurland, G., Fatal myocardial infarction in marathon racing, Ann. Intern. Med., 84 (1976) 704. 4 Ullyot, J., The Medical Report. Runners World, 11 (September 1976) 16. 5 Noakes, T.D., Opie. L.H., Beck, W., McKechnie, J.W., Benchimol. A. and Desser. K., Coronary heart disease in marathon runners. Paper read at the New York Academy of Sciences Conference on the Marathon, New York City, October 1976. 6 Cardello, F., Marathon vs distance running, New Engl. J. Med., 294 (1976) 115. 7 Morris, J.N., (Ed.), Uses of Epidemiology, Churchill-Livingstone, Edinburgh, London, New York, 1975. PP. 121-141. 8 Dayton, S.. Long distance running and sudden death, New Engl. J. Med., 293 (1975) 941.
MRC Heart Disease Research Unit, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town (South Africa) (Received (Accepted
14 January, 18 January,
1977) 1977)
T.D. NOAKES L.H. OPIE
