Mini review examines sudden cardiac death risks in marathon runners across different age groups

Marathon running is widely promoted for its cardiovascular and overall health benefits, yet rare cases of sudden cardiac death (SCD) during long-distance races continue to raise substantial clinical and public health concerns. Although the absolute incidence of marathon-associated SCD is low, its catastrophic nature necessitates a clearer understanding of risk perception, epidemiological patterns, pathophysiological mechanisms, and preventive strategies. This mini review synthesizes current evidence on the incidence, demographic characteristics, etiological spectrum, and temporal features of cardiac arrest and SCD during marathon running. Available data indicate that risk is higher in men, older runners, and full-marathon participants, with most events occurring in the final phase of the race or shortly after finishing. Coronary artery disease remains the predominant cause in middle-aged and older runners, whereas inherited cardiomyopathies, congenital coronary anomalies, and myocarditis are more relevant in younger athletes. We further discuss the mechanistic basis of exercise-triggered fatal events, including acute ischemia, malignant ventricular arrhythmias, myocardial fibrosis, and inflammatory myocardial injury. Current preventive approaches, including pre-participation cardiovascular screening, electrocardiography, advanced imaging, genetic evaluation in selected individuals, and rapid on-site resuscitation systems, have improved event recognition and survival outcomes, but important controversies persist regarding optimal screening intensity, interpretation of subclinical findings, and the dose-response relationship between extreme endurance exercise and cardiovascular risk. Future efforts should prioritize precision risk stratification, longitudinal evaluation of subclinical cardiovascular abnormalities, integration of wearable monitoring technologies, and standardized race-day emergency preparedness to improve the safety of long-distance running.