To the Editor: In their Research Letter, Dr Harris and colleagues1 provided information about sudden death during the triathlon. In light of the increasing participation in triathlon events, as well as in open water swimming, more athletes might require urgent medical care. Further understanding of the causes and settings of sudden death in such competitions could greatly assist in medical team preparedness. We would therefore like to consider the possible mechanisms of deaths during the swimming part of the triathlon.
As the authors stated, the swimming segment is crowded and chaotic. A simple loss of consciousness for any reason, which could be easily identified on the ground, could result in drowning and death when occurring in water. Therefore, enhanced monitoring of athlete safety in this part could be warranted in contest regulations.
The drowning process is a complex continuum,2 and data on the presence of fluid in the lungs on autopsy (drowning with aspiration) could have assisted in identifying the actual cause of death: whether the participant gasped for air or lost consciousness rapidly with a resultant apnea. These data could be of use to resuscitating personnel, in the field or in the hospital, for focusing their treatment efforts.
Another important factor predisposing swimmers to sudden death is the arrhythmogenic effect of water. The combination of voluntary apnea, cold water exposure, and face immersion may result in increased sympathetic and parasympathetic activity,3 possibly causing ventricular premature beats. Triathlon regulations require a minimal water temperature. Water temperature was not described in the article, but relatively cold water even within the allowed range could have been a contributing factor to these fatal events.
The authors described several underlying cardiac abnormalities identified in autopsies, such as left ventricular hypertrophy and a congenital coronary anomaly, as well as a history of Wolff-Parkinson-White syndrome. Type 1 long QT syndrome, and to a lesser extent catecholaminergic polymorphic ventricular tachycardia, may be associated with malignant arrhythmias during swimming.4 These conditions may be picked up by a preparticipation examination that includes a detailed medical history, a proper physical examination, and a resting electrocardiogram.5
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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