Triathlon and Your Heart: What to Check Before Racing in Dubai

Andrei Prikhodko — GP, cardiologist

Why check your heart if you feel fine

I see people who run marathons, ride a hundred kilometers on the weekend and swim in the Gulf. Almost all of them are healthy, and the training does them good. But a long race means hours of hard effort, often in the heat. Sometimes it brings out a problem that has stayed silent for years. A pre-race check is there to find it before the start line does.

What we know about risk in marathons and triathlons

Kim and colleagues (NEJM, 2012) looked at US marathons and half marathons from 2000 to 2010: 10.9 million runners and 59 cardiac arrests, or 0.54 per 100,000 participants. Of those 59 cases, 42 were fatal. The rate was 1.01 per 100,000 in marathons and 0.27 in half marathons, and clearly higher in men than in women. The main causes were hypertrophic cardiomyopathy and coronary atherosclerosis. Runners who received bystander CPR right away were more likely to survive.

Triathlon numbers are higher. Harris and colleagues (Annals of Internal Medicine, 2017) reviewed USA Triathlon data from 1985 to 2016: about 4.8 million participants and 135 sudden deaths, resuscitated cardiac arrests or trauma deaths. That is 1.74 per 100,000 participants: 2.40 in men, 0.74 in women and 18.6 in men aged 60 and older. The average age was about 47, and 85% were men. Of the sudden deaths and cardiac arrests, 90 happened during the swim, 15 during the run, 7 on the bike and 8 after the finish. Autopsies were done in 61 of those who died; 27 of them (44%) had significant heart or blood vessel disease, most often coronary atherosclerosis or cardiomyopathy.

The absolute risk is small. But the pattern repeats: a middle-aged man, a condition he did not know about, and most often the first leg of the race, the swim.

What European guidelines recommend

The European Society of Cardiology (ESC) 2020 guidelines on sports cardiology split the approach by age.

• Under 35. Before competition: a questionnaire, a physical exam and a 12-lead ECG. According to the ESC, the ECG picks up more than history and exam alone. The guidelines do not recommend echocardiography for routine screening, as the evidence is not there.
• Over 35. At this age, most events are caused by coronary atherosclerosis. So risk is assessed with the SCORE chart (age, blood pressure, cholesterol, smoking), taking diabetes and early heart disease in the family into account.
• People who have been inactive or are at high risk and plan intense training: a physical exam, an ECG and an exercise stress test. For people with diabetes, the ESC advises a cardiovascular assessment before starting intense exercise.
• A stress test for everyone without symptoms is not recommended: at low risk it often raises false alarms.

I covered what a basic heart check includes, and in what order, in the article on how to check your heart.

Atrial fibrillation after years of endurance training

This one matters for people with many years of endurance sport behind them. In a meta-analysis by Newman and colleagues (British Journal of Sports Medicine, 2021), athletes had 2.46 times higher odds of atrial fibrillation than non-athletes, and the link was stronger in athletes under 55. The ESC notes that atrial fibrillation is more common in active and former male masters athletes and in people doing high-intensity endurance sports. In women, this link has not been confirmed.

What to watch for: skipped beats, sudden episodes of fast heartbeat, dizziness, and a drop in performance you cannot explain by your training. Episodes can be short and missed on a standard ECG. A 24-hour monitor helps catch them.

When to stop a workout

Stop and see a cardiologist before your next session if during exercise you notice:

• chest pain, pressure or burning;
• skipped beats or a fast heartbeat that does not settle with rest;
• shortness of breath out of proportion to your pace;
• dizziness or a feeling that you are about to faint.

Fainting during exercise, or chest pain that does not go away at rest, is a reason to seek emergency care right away. How to tell heart-related chest pain from other causes is covered in the article on chest pain.

Heat: training in Dubai

Most races in the UAE take place in the cooler months, but training for them often runs into the heat. The international consensus on training and competing in the heat (Racinais and colleagues, 2015) names heat acclimatization as the most effective measure: repeated training sessions in the heat over 1–2 weeks. Start workouts and races well hydrated and avoid becoming dehydrated during exercise.

• Train outdoors early in the morning or in the evening.
• If you are back from a summer in a cooler country, cut volume and pace for the first weeks.
• Exertional heat stroke is a medical emergency. The ACSM advises stopping exercise at once and cooling the whole body as fast as possible. I listed the signs of overheating in the cardiologist's guide.

Drink to thirst, not ahead of it

Dehydration is a risk, but long races have the opposite problem too: hyponatremia, a drop in blood sodium. The 2015 international consensus statement (Hew-Butler and colleagues) names its main cause: drinking water, sports drinks or other fluids beyond what the body loses and can clear. The advice to "drink before you get thirsty" pushes some athletes into this. At first there may be no symptoms; later come headache, vomiting, confusion and seizures. The consensus recommends drinking when you are thirsty. In the heat you will be thirsty more often, and that is normal.

A medical certificate for the race

Some races ask for a medical certificate. In Italy, for example, a foreign runner who is not a resident is usually allowed to bring a certificate from their own country, but it must cover the same tests Italian law requires: a medical exam, urinalysis, an ECG at rest and after exercise, and spirometry. In Russia, organizers of mass running events usually ask for a medical clearance on the Ministry of Health form. The requirements are set by the rules of each race, so read them early and bring them to your appointment.

What we can do at GMS

I see patients at our clinic in Downtown Dubai, in English and Russian. For race preparation we have two programs.

Race Clearance — 1,500 AED. A cardiologist consultation and an ECG; if your joints, tendons or muscles bother you, a soft tissue ultrasound. At the end I issue a medical clearance certificate for the race. If the race rules ask for more, such as spirometry (500 AED) or urinalysis, I will tell you in advance what to add.

Athlete Health Check-up — 6,200 AED. A cardiologist consultation with a review of results and recommendations, an ECG, 24-hour Holter monitoring, echocardiography, spirometry, and ultrasound of the abdomen and arteries. Lab tests: complete blood count with differential, glucose, HbA1c, lipid profile, liver panel, creatinine, uric acid, sodium, potassium, chloride, TSH, ferritin, vitamin D and urinalysis. ESC guidelines do not require echocardiography and Holter monitoring for every athlete. People choose this program when they train for long distances, especially after 35 or when returning after a break, and want a full baseline. Whether further tests are needed, we decide based on the results.

If you have a single question, you can start with a cardiologist consultation (750 AED) and an ECG (400 AED). If you need a stress test, a coronary CT scan or a hospital stay, the GMS medical concierge will arrange it at a partner hospital, handle the paperwork and translation, and your GMS doctor stays in charge of your care. More about the department is on the cardiology page.

You can book with Andrei Prikhodko, GP, cardiologist, through the form on our website or on WhatsApp.

Sources

• ESC. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease (2020)
• Kim JH et al. Cardiac Arrest during Long-Distance Running Races, N Engl J Med (2012)
• Harris KM et al. Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016: A Case Series, Ann Intern Med (2017)
• Newman W et al. Risk of atrial fibrillation in athletes: a systematic review and meta-analysis, Br J Sports Med (2021)
• Racinais S et al. Consensus recommendations on training and competing in the heat, Br J Sports Med (2015)
• Roberts WO et al. ACSM Expert Consensus Statement on Exertional Heat Illness, Curr Sports Med Rep (2021)
• Hew-Butler T et al. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Br J Sports Med (2015)
• FIDAL. Regolamento Maratona Mugello (2024)
• Russian Ministry of Health. Order No. 1144n on medical care for people engaged in physical activity and sport, with the race clearance form (2020)

FAQ

Do I need a heart check before a marathon or triathlon?

The ESC 2020 guidelines advise a questionnaire, a physical exam and an ECG before competition, and after 35 an assessment of atherosclerosis risk based on blood pressure, cholesterol, smoking, diabetes and family history. People who have been inactive or are at high risk need an exercise stress test before intense training. The guidelines do not recommend echocardiography for everyone.

How risky is triathlon for the heart?

The absolute risk is small. In USA Triathlon data from 1985 to 2016, sudden death, cardiac arrest or trauma death occurred in 1.74 per 100,000 participants, and in 18.6 per 100,000 men aged 60 and older. Most sudden deaths and cardiac arrests happened during the swim, and 44% of those who had an autopsy were found to have significant heart or blood vessel disease.

Which symptoms during training should worry me?

Chest pain, pressure or burning, skipped beats or a fast heartbeat that does not settle with rest, breathlessness out of proportion to your pace, and dizziness. With these symptoms, stop the workout and see a cardiologist before the next one. Fainting during exercise, or chest pain that does not go away at rest, is a reason to seek emergency care right away.

How much should I drink during a long race in the heat?

The 2015 international consensus on exercise-associated hyponatremia recommends drinking when you are thirsty. Drinking beyond your losses dilutes blood sodium and can cause headache, vomiting, confusion and seizures. In the heat you get thirsty more often, so you will drink more.

How much do the Athlete Health Check-up and Race Clearance cost at GMS?

Race Clearance costs 1,500 AED: a cardiologist consultation, an ECG, a soft tissue ultrasound if your joints or muscles bother you, and a medical clearance certificate. The Athlete Health Check-up costs 6,200 AED and adds 24-hour Holter monitoring, echocardiography, spirometry, abdominal and arterial ultrasound, and an extended set of blood and urine tests.

This article is for information only and does not replace a consultation. If you have symptoms, see a doctor.

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