A news report about the Ironman Philippines 70.3 triathlon race last week caught my attention. A relay participant, Ramon Igana, Jr., 44 years old, died during the bike portion of the event and autopsy findings suggested that acute pulmonary embolism was the cause.
Reporting on the event does not make mention of previous medical problems, but the victim's wife, a physician, reported that Igana felt well on the morning of the race. Witnesses reported that Igana was seen wobbling on the bike and appeared pale shortly before he suddenly fell to the ground. I can't find mention of the resuscitation efforts on the scene, but he was taken to a nearby hospital where he was pronounced dead on arrival.
Let's quickly review the medical issue of pulmonary embolism. This is a condition in which blood clots form somewhere in the body's venous system (deep venous thrombosis, or DVT), become dislodged, and are carried with the bloodflow to the right side of the heart. From there, the blood and blood clots are pumped to the pulmonary arteries which carry blood flow to the lungs. The blood clot(s) become lodged in the branches of the pulmonary arteries, impairing proper blood flow to the lungs. This process is called thromboembolism. And when it occurs suddenly, we call the problem acute pulmonary embolism.
Pulmonary embolism produces several symptoms, depending upon the severity, or amount of blood clot that becomes deposited in the lungs. Shortness of breath, increased heart rate, and chest pain or discomfort are common symptoms. In serious cases, there can be almost complete obstruction to blood flow in the lungs, and this can lead to fatal cardiac arrest. The diagnosis is usually established by chest CT scan and the conventional treatment is with blood thinning medications (eg, heparin, Coumadin) to prevent additional blood clots from forming.
But interestingly, although pulmonary embolism is responsible for as many as 200,000 deaths per year in the United States, this is a very uncommon problem for athletes. We know that the risk factors for the development of DVT, the precursor for pulmonary embolism, include immobilization, a diagnosis of cancer, or previous history of DVT--and all of these would be relatively uncommon among active athletes. But it can occur. Professional tennis player, Serena Williams, is the most recent high-profile athlete to be affected by pulmonary embolism and her story has been shared widely in the popular press.
I've shared previously here at the blog that I've been a part of a medical panel at USA Triathlon that's reviewed event-related fatalities over the past decade. I can share that pulmonary embolism was not identified as a cause of death in any of the 45 victims. I'm also not aware of any other reporting on triathlon race-related fatalities due to pulmonary embolism. And that's why the report from the Philippines caught my attention.
Sports-related sudden cardiac arrest (SCA) has received increasing attention because of the increasing popularity of recreational sporting activities worldwide. Pulmonary embolism is an uncommon cause of sports-related SCA, occurring in approximately 0-2% of victims, depending upon the popoulation studied.
A quick search of the medical literature shows just a single case report of non-fatal pulmonary embolism in a triathlete. This was a 33 year old woman who completed a half Ironman triathlon and developed lower extremity swelling and pain 3 weeks later. These symptoms were followed by the abrupt onset of increasing shortness of breath and light-headedness. In retrospect, her caregivers speculated that a 3-week period of rest following her triathlon event resulted in relative immobility that was the "set-up" for the development of DVT.
DVT is the precursor for pulmonary embolism and usually occurs in the lower extremities. In some athletes, the veins of the upper extremity can be affected in a condition known as effort thrombosis. The typical symptoms are swelling, tenderness, and pain in the affected extremity. Athletes should be vigilant for such symptoms and seek treatment for DVT in order to prevent pulmonary embolism.