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Case Reports
. 2024 Apr 19;8(5):ytae202.
doi: 10.1093/ehjcr/ytae202. eCollection 2024 May.

A case series of eight amateur athletes: exercise-induced pre-/syncope during the Zurich Marathon 2023

Greta Hametner  1 , Doris Eis  2 , Muriel Kruijver  1 , Michael Stiefel  1 , Jan Gerrit van der Stouwe  1   3 , Melina Stüssi-Helbling  4 , Anja Forrer  4 , David Niederseer  1   5   6
Affiliations
Case Reports

A case series of eight amateur athletes: exercise-induced pre-/syncope during the Zurich Marathon 2023

Greta Hametner et al. Eur Heart J Case Rep. .

Abstract

Background: Marathon running poses unique cardiovascular challenges, sometimes leading to syncopal episodes. We present a case series of athletes who experienced pre-/syncope during the Zurich Marathon 2023, accompanied by elevated cardiac biomarkers.

Case summary: Eight athletes (2 females, 6 males) aged 21-35 years, with pre-/syncope and various additional diverse symptoms such as dizziness and palpitations during the (half-)marathon, were admitted to two emergency departments in Zurich, Switzerland. Clinical evaluations included electrocardiogram, echocardiography, telemetry, coronary computed tomography (CT) scans, and cardiac biomarker assessments. High-sensitive troponin T (hs-cTnT) was elevated in all cases at initial assessment and returned to normal at follow-up. All athletes who received CT scans had normal coronary and brain CT results. None of the eight athletes had underlying cardiovascular disease. Renal function normalized post-admission, and neurological symptoms resolved within hours. Creatinine levels indicated transient acute kidney injury. A common feature was inexperience in running, inadequate race preparation, particularly regarding fluid, electrolyte, and carbohydrate intake, along with pacing issues and lack of coping strategies with heat.

Discussion: From a clinician perspective, the case series highlights the challenge in the management of patients with a pre-/syncopal event during strenuous exercise and elevated cardiac biomarkers. Diverse initial symptoms prompted tailored investigations. Adequate training, medical assessments, and awareness of syncope triggers are essential for marathon participants. Caution and pacing strategies are crucial, especially among novices in competitive running. This information is pertinent given the growing popularity of marathon events and prompts a standardized diagnostic approach after these events.

Keywords: Cardiac biomarkers; Case series; Collapse; Marathon; Syncope.

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Conflict of interest statement

Conflict of interest: DN declares no conflict of interest related to this work; outside this work he received honoraria, consultant fees and/or travel expenses from Abbott, Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Dr Willmar Schwabe GmbH & Co. KG, Emilwood Service Limited, Gerson Lehman Group (GLG) Consulting, Novartis, Novo Nordisk, Pfizer, walk and feel, and Zoll. All other authors have nothing to declare.

Figures

Figure 1
Figure 1
Patient 2: (A) creatine kinase levels on admission and at follow-up, (B) troponin levels on admission and at follow-up, and (C) computed tomography scan of the brain after the marathon: blue arrow shows non-specific small calcification in the 4th ventricle, no bleeding, no acute territorial infarction, and normal external and internal cerebrospinal fluid spaces.
Figure 2
Figure 2
Patient 3: (A and B) coronary computed tomography: normal coronary anatomy, no coronary atherosclerosis. (C) Echocardiography including strain imaging reveiled normal left ventricular function.
Figure 3
Figure 3
Patient 6: (A) coronary computed tomography after the marathon showing normal coronary anatomy and no coronary atherosclerosis of the left anterior descending artery, (B) electrocardiogram after the marathon, (C) creatine kinase levels after marathon and at follow-up, and (D) troponin levels after on admission and at the follow-up.
Figure 4
Figure 4
Patient 7: (A) mildly dilated left atrium left atrial volume index 35 mL/m² immediately after marathon/syncope, (B) normalized atrium at the follow-up after 8 weeks left atrial volume index 20 mL/m², (C) creatine kinase levels initial and at follow-up, and (D) troponin levels on admission and at follow-up.
None
See this image and copyright information in PMC

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