• aspirin
• coronary thrombosis
• marathon running

As if reprising the index case of Pheidippides in 490 BC, the sudden cardiac death of a 32-year-old modern-day warrior at mile 20 in the 2016 London marathon mandates an expedited search to prevent such tragic events based on novel insights into the underlying cause (figure 1).1 2 Although the cardiac findings in this case have not been released, an acute coronary event is most likely as the most common cause of sudden cardiac death in men over the age of 30 years including among experienced runners in that event.3–5

While the overall incidence of sudden cardiac death during marathons is low, cardiac arrests occur in roughly 1 in 50 000 finishers.6 Based on 59 cases with a mean age of 42 years in a 10-year prospective registry of American road races since 2000, male sex and the marathon were the only significant risk factors for cardiac arrest.7 Atherosclerotic heart disease was the predominant underlying cause in same-aged runners in a concurrent Parisian registry.8 Marathon running thereby illustrates the triggering of acute myocardial infarction by strenuous exercise in middle-aged males with underlying non-obstructive coronary atherosclerosis.9