Risk of Death During Exercise

This is not a topic that is often considered, but for those of you that are genuinely curious, we might as well get the information out on the table. It is no secret that when a person exercises, depending on their intensity, they are increasing the stress on their body and if the body cannot handle said stress, it will give out in some way or another; usually, the body will simply force the person to stop exercising in some mild manner, but for some, if they are predisposed or push their body too much, it can be life threatening. In this article, we will examine the prevalence of death in exercise and the most common reasons why healthy and assumed healthy people die while exercising – let us get our mortality on!

What is the risk of death in cardio exercise?

This is highly dependent on the conditions we are examining, but if we break these conditions down a bit, we can get a clearer picture.

The prevalence of death among athletes, or assumed highly fit individuals, in aerobic, cardiovascular exercise is about 1 in 133,000 in men (0.0008%) and 1 in 769,000 in women (0.0001%)[1]. Conditions such as age and intensity apply, however. Most, although not all, athletes are younger (teens, twenties) so these numbers do not necessarily extend to all athletes. In healthy adults, the rate of death from cardiovascular exercise is as high as 1 in 18,000 in men (0.0056%) and undetermined in women [1][5]. As for the casual exerciser, sexes undivided, the death rate is 1 in 82,000 (0.0012%) with only 16% chance of that death being a woman; however, almost half of those who died during exercise would be categorized as regularly sedentary as they exercised irregularly or only once a week [1].

If we take into consideration intensity and bump it up from mild or moderate exercise intensity to vigorous exercise intensity, we have little data on the topic, but what data we do have indicates risk increase somewhere in the range of 1 in 593 (0.1686%) –  1 in 3852 (0.0260%)[1].

Now, in full disclosure, these numbers are based on cardiopulmonary deaths and do not reflect all-cause mortality; however, we can safely assume these numbers are relatively accurate (barring normal study limitations) as most aerobic stress is put on the cardiopulmonary systems. So, while a person could die from other reasons, a healthy person would almost assuredly die from a heart or circulatory related issue if they were to die during exercise. We can also safely say that risk increases as age increases, as intensity increases, as frequency of exercise decreases (and, although not covered, as previous disease state increases) – more on this later [1][5].

Explain this trend?

It may be interesting for us to understand why people die during aerobic exercise. People die during aerobic exercise for a variety of reasons, although some of the more prominent reasons are related to cardiovascular disease, especially in holder individuals. Risk increases with age, because the body becomes less pliable and arteries harden leading to arteriosclerosis, as well as atherosclerotic conditions (being overweight, smoking, etc.) leading to atherosclerosis [2][3]. This restriction of the blood flow throughout the body can lead to stroke in the head (no blood flow to brain), traumatic aortic rupture (artery explodes), myocardial infarction (heart attack), among other life threatening internal injuries [3][6]. These are simply consequences of aging and although they can be mitigated, they can still occur in the majority of people if disease is prevalent enough.

On another note, intensity of exercise increases the demand of blood throughout the body, so as exercise intensifies, the heart and lungs must work harder by pumping faster and more powerfully than at rest or in a more mild state of exercise. This being the case, this can also lead to the same conditions described in the last paragraph.

Thirdly, if a person goes to the gym infrequently and is generally sedentary, their body is simply not used to this sudden massive demand and can fail in delivery, also leading to the consequences described in the initial paragraph.

Finally, although the risk would be even higher than described in the statistics brought up in the last section, a person with undiagnosed cardiovascular disease would have an especially susceptible propensity to have a fatal health issue during exercise [6]. Another possibility, and likely the most probable in young deaths (below age 35), is the prevalence of genetic abnormalities leading to a variety of potential issues in the cardiac, pulmonary, or circulatory systems like hypertrophic cardiomyopathy [5].

Now, as a quick word to the statistics between men and women – while there is little data on women, this is likely due to the fact that women tend to develop cardiopulmonary issues later in life than men [4][6]. That said, risk still remains, but it is relatively safe to assume that male risk will always remain higher than pre-menopausal women – this is far less the case for post-menopausal women.

 

In this area, there is almost no data and what data there is needs to be substantiated further; however, luckily, one study examined exactly this question, so we can garner some information from it. Again, there are various parameters to consider from the intensity of the strength training, the type of exercise, the subject and his/her health, time exposed to resistance (strength) training, among other such factors. However, in a study examining health markers in 6,653 participants who underwent strength training had no fatalities nor near fatal situations [7]. This means that, according to this study, there is less than a .0150% chance of a fatal incident from weight lifting; however, the exact number cannot be concluded [7]. These people, aged between 20 – 69 years of age and with a mix of men (5,460) and women (1,193), underwent 1-repetition maximum tests. This means, that with a maximal or near maximal intensity, no person had any life threatening health issue; all of these people were prescreened and were deemed either completely healthy or having minimal health issues [7]. Also, 4,500 more people, aged 18 to 93, were assessed in a separate instance performing over 20,000 maximal strength tests, and again, no fatal situations were reported [7].

Explain this trend?

It seems that strength training has no inherit risk in causing fatalities, but even with these few studies, there are a few aspects to consider.

These 1-repetition maximums were performed with the instruction not to go through the Valsalva maneuver, which could skew results as the inclusion of the Valsalva maneuver could increase risk, not to mention the exclusion of the Valsalva could lead to improper 1-repetition maximums as the Valsalva is determined necessary in resistance at or over 80% intensity, of which 1 repetition maximum is 100% intensity [7][8]. However, since Valsalva’s impact on risk is currently debated, it is impossible to make a fair assessment without further information [8]. It has been shown that the Valsalva maneuver increases intra-abdominal pressure on its own and that it also may be a contributing factor to increasing blood pressure [9]. I would also mention that the exercise selection in this study was limited to bench press and leg press, which, while adequate in overall measure, may not be indicative of risk in more demanding exercises like the barbell squat where the weight is literally pushing down on your body and needs to be braced – this could have a small effect.

So, taking all this into consideration, healthy individuals have an undetermined specific risk, but a known low risk of mortality from weight lifting (physiologically speaking) regardless of age and intensity if the Valsalva maneuver is avoided and potentially if the Valsalva maneuver is used, even. While not discussed in this article, even mildly hypertensive individuals run a low risk of any serious complications, but there still requires more research on the topic beyond the few studies examining the issue to add reliability to these claims. Any potential dangers would, as with cardiovascular exercise, come from a moderate or severely affected cardiovascular system. 

SUMMARY

All in all, what can we say to round this all up? Well, we know that the prevalence of death among younger, and/or athletic aerobic types is highest by a long shot in men, but even then it is extremely rare at 0.0008% chance. We know that chance increases in adulthood, but again, the rate is still extremely low with risk increasing in all types as intensity, level of related disease, and previous sedentariness increase. In terms of strength training/anaerobic exercise, there is little data on the topic, but in viewing cardiovascular health issues, the few studies performed found an exceedingly low level of incident rating at somewhere under 0.0150% chance; how much lower is unknown at this time. In these cases, it is also wise to consider that valsalva maneuvers were not performed in study, which could have an impact on increasing mortality risk. Overall, however, exercise in healthy populations, regardless of age, is extremely safe if performed correctly and tends to be highest risk at the highest intensities, although this risk is still low.

Writer: Nicolas Verhoeven

                                                                                                        Citations

[1] Thomas, P. D. (2007). Exercise and Acute Cardiovascular Events. Circulation, 115(17). Retrieved from http://circ.ahajournals.org/content/115/17/2358

[2] Wang, J. C. (2012). Aging and Atherosclerosis. Circulation Research, 111, 245-259. Retrieved from http://circres.ahajournals.org/content/111/2/245.full

[3] Atherosclerosis. (2015). Retrieved from American Heart Association website: http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Atherosclerosis_UCM_305564_Article.jsp#.V7EYl00rKUl

[4] Maas, A., & Appelman, Y. (2010). Gender differences in coronary heart disease. Neth Heart J,18(12), 598-603. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3018605/

[5] Sudden Cardiac Death in Athletes. (n.d.). Retrieved from http://www.rice.edu/~jenky/sports/sudden.death.html

[6] Northcote, R. J., Flannigan, C., & Ballantyne, D. (1986). Sudden death and vigorous exercise--a study of 60 deaths associated with squash. Heart, 55(2), 198-203. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232118/?page=5

[7] Gordon, N. F., Kohl, H. W., Pollock, M. L., Vaandrager, H., Gibbons, L. W., & Blair, S. N. (1995). Cardiovascular safety of maximal strength testing in healthy adults. The American Journal of Cardiology, 76(11), 851-853. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/7572673?access_num=7572673&link_type=MED&dopt=Abstract

[8] Hackett, D. A., & Chow, C. (2013). The Valsalva Maneuver. Journal of Strength and Conditioning Research, 27(8), 2338-2345. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23222073

[9] Palatini, P., Mos, L., Munari, L., Valle, F., Torre, M. D., Rossi, A., … Palù, C. D. (1989). Blood pressure changes during heavy-resistance exercise. Journal of Hypertension, 7, S72-73. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2632751

What is the risk of death in strength training?

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