Health Parameters of a 62-Year-Old Athlete with Moderate Cardiovascular Risk During a 27-Day Ultra-Endurance Run: A Case Report

terest and participation in running as a sport are continuously increasing among runners, particularly those over the age of 35. Runners may encounter adverse medical conditions in races involving long distances, such as ultramarathons. Interactions between runners and their family physicians play a crucial role in maintaining runner health. This case presentation examines the blood tests conducted under the guidance of a family physician and the assessment of sports performance of a 62-year-old male runner during and after a 27-day running program. This case study aims to investigate adverse medical conditions that runners may face, including acute kidney injury and exercise-associated hyponatremia, along with strategies to safeguard runner health. Keywords: acute kidney injury, hyponatremia, rhabdomyolysis, running, health Date of submission: 27.08.2024 / Date of acceptance: 23.12.2024 How to cite: Yildiz S, Vardar SA. Health parameters of a 62-year-old athlete with moderate cardiovascular risk during a 27-day ultra-endurance run: a case report. Euras J Fam Med 2024;13(4):209-14. doi:10.33880/ejfm.2024130408. Conflict of interest: No conflict of interest was declared by the authors. Financial disclosure: No financial disclosure was declared by the authors.

Yildiz S et al. Health parameters of a 62-year-old athlete during a 27-day ultra-endurance run. Euras J Fam Med 2024;13(4):209-14 210 Introduction In recent years, with the increase in interest in running sports, participation in collective endurance races such as marathons and ultramarathon races has increased (1). Nevertheless, some runs are planned and organized individually and with a purpose. An ultramarathon is a running event exceeding the traditional marathon distance of 42.195 kilometers. Additionally, runs exceeding six hours in duration may be classified as ultra-endurance runs (2,3). There is an increase in participation in running activities, especially among master runners over the age of 35, and this trend is expected to increase further in the coming years (1,4). The increase in older runners in long-distance events and individual runs is significant regarding potential adverse medical conditions during or after running, as well as positive aspects. The specialty of family medicine is a key point of contact in protecting and enhancing the health of runners, as it monitors the population it is responsible for throughout their lives and provides health services even during periods of good health. This interaction with the family physician represents a crucial opportunity to prevent potential medical issues before, during, and after running. When assessing runners, it is crucial to consider the impact of endurance running on the musculoskeletal system. In ultra-endurance events, overuse injuries to the musculoskeletal system are common, with the legs, feet, and knees most frequently affected (5). Creatine kinase (CK) and lactate dehydrogenase (LDH) levels can be elevated in running-induced muscle damage, and these elevations are influenced by the distance run (6). Rhabdomyolysis is a potentially fatal condition marked by the release of muscle cell contents, such as CK, LDH, myoglobin, and potassium due to muscle damage (7). To diagnose mild rhabdomyolysis, it is recommended to consider the presence of acute muscle weakness, myalgia, and muscle swelling alongside a CK level exceeding 1000 IU/L or CK levels that are five times the upper limit of normal (8). Runners are also at risk of acute kidney injury (AKI). In a systematic review of ultramarathon

due to muscle damage (7). To diagnose mild rhabdomyolysis, it is recommended to consider the presence of acute muscle weakness, myalgia, and muscle swelling alongside a CK level exceeding 1000 IU/L or CK levels that are five times the upper limit of normal (8). Runners are also at risk of acute kidney injury (AKI). In a systematic review of ultramarathon runners by Lecina et al. (9), the incidence of AKI was 42.04%. Runners who experience have elevated CK levels are more likely to develop AKI (10). Although AKI is common, it is important to assess runners for in this regard, as mild damage often goes undetected. The systemic and metabolic effects associated with running should also be considered. Exercise- induced hyponatremia is the main metabolic problem associated with prolonged running. This condition can manifest with symptoms ranging from dizziness and fatigue to confusion and potential coma if serum sodium concentration decreases below 135 mmol/L during or within 24 hours post-activity, which may be life-threatening (11). Exercise-induced hyponatremia may arise from sodium reduction due to sweating or excessive fluid intake prior to or during running (12). Exercise-induced hyponatremia is a risk for athletes and requires caution, particularly in long-duration sports such as ultramarathon running. In this case, the blood analyses conducted during and after a 27-day individual run by a master runner, as directed by his family physician, will be evaluated along with his athletic performance. With this case report, we aimed to examine the potential adverse medical conditions that runners may encounter and strategies to protect runner health. Figure 1. From the beginning to infinity: The respect run for Atatürk

Yildiz S et al. Health parameters of a 62-year-old athlete during a 27-day ultra-endurance run. Euras J Fam Med 2024;13(4):209-14 211 Case Report “From the Beginning to Infinity: The Respect Run for Atatürk” planned individually by runner F.K. to commemorate the 100th anniversary of the Republic of Türkiye, started in Thessaloniki on 23 April 2023 and finished in Ankara on 19 May 2023, covering 800 km in 27 days (Figure 1). The runner has been informed, and consent has been obtained for the case presentation. The runner, a 62-year-old male, had no history of any diseases and is actively practicing as a dentist. However, there was a family history of sudden cardiac death, with his father dying at the age of 46. The patient is not currently taking any medications. The athlete, who had an active sports background in childhood, was also interested in various sports, including football, volleyball, and basketball. The athlete completed his first long-distance run at 25 by participating in the 15 km public run of the Eurasia Marathon (İstanbul-Türkiye) and reported starting regular running training at 30. He has participated in over 20 marathons, ultramarathons, and ultra-trails both in Türkiye and abroad. The athlete increased training sessions for the run. The athlete ran 4 hours daily at 7.5 km/h, starting at 7 AM. The athlete communicated with his family physician during the race intervals, reported no significant complaints, and did not take any medications. The athlete reported a 2 kg weight loss by the end of the run. The athlete had blood tests at hospitals along the running route on his family physician's advice. Hemogram test results performed during and after the run were within normal limits. There were no other findings in biochemical parameters except for a twice the upper limit of CK level on the 11th day of the run and slight increases in AST and ALT values on the 18th day. Post-run tests showed that CK levels were at the normal upper limit (Table 1). Table 1. Hematological and biochemical parameters of the athlete Parameters 13.06.2023 21.05.2023 08.05.2023 03.05.2023 Leukocyte (µL) 8.20 8.56

for a twice the upper limit of CK level on the 11th day of the run and slight increases in AST and ALT values on the 18th day. Post-run tests showed that CK levels were at the normal upper limit (Table 1). Table 1. Hematological and biochemical parameters of the athlete Parameters 13.06.2023 21.05.2023 08.05.2023 03.05.2023 Leukocyte (µL) 8.20 8.56 11,29 8.52 Erythrocyte (µL) 4.88 5.08 4.46 4.59 Hemoglobin (gr/dl) 14.7 13.3 13.2 13.6 Hematocrit (%) 43.7 43.9 39 41.2 Platelet (µL) 296 336 332 330 tGFR (ckd-epı) 86.54 96 96 96 Sodium (mmol/L) 139 136 138 135 Chlorine (mmol/L) 102 103 106 104 Potassium (mmol/L) 4.9 4.68 4.73 4.48 Calcium (mg/dL) 9.6 9.9 9 9.1 FBG (mg/dL) 96 105 105 109 Urea (mg/dL) 29 30 36 34.6 Creatinine (mg/dL) 0.94 0.8 0.8 0.8 ALT (U/L) 18 35 63 39 AST (U/L) 18 29 67 34 ALP (U/L) 58 - 46 48 CK (U/L) 206 - - 441 tGFR: Total glomerular filtration rate; FBG: Fasting blood glucose; ALT: Alanine transaminase; AST: Aspartate transaminase; ALP: Alkaline phosphatase; CK: Creatine kinase The runner's athletic performance was assessed 25 days post-run in the Sports Physiology Laboratory at Trakya University. Before the cardiopulmonary test, the physical examination indicated normal findings in all system assessments. No active complaints were noted. On test day, the runner's height was 171 cm, weight 69 kg, and body mass index 23.6. The runner's body fat percentage was 15.8%, resting blood pressure 104/68 mmHg, and pulse rate 72 bpm. The Bruce Protocol is one of the most commonly used protocols

Yildiz S et al. Health parameters of a 62-year-old athlete during a 27-day ultra-endurance run. Euras J Fam Med 2024;13(4):209-14 212 in cardiopulmonary exercise testing. It is performed by increasing the speed and incline every 3 minutes. The first phase starts at a speed of 2.7 km/h and a 10% incline. In the second stage, the speed increases to 4.0 km/h and the incline is increased to 12%. In the third stage, the speed is increased to 5.4 km/h and the gradient to 14%. The test continues in this way, increasing the speed and incline every 3 minutes. The Modified Bruce Protocol is a modified version of the Bruce Protocol with two low-intensity stages added to the beginning. The first stage is at a speed of 2.7 km/h and 0% incline, the second stage increases the incline to 5% while the speed remains constant at 2.7 km/h. From the third stage onwards, it continues with the standard stages of the Bruce Protocol (13). The runner had a moderate cardiovascular risk according to ACSM criteria (14). Considering the athlete's age and the history of sudden cardiac death in a first-degree relative (father), the modified Bruce protocol was used. The runner completed a cardiopulmonary exercise test that lasted 11.22 minutes. At 11.20 minutes of the test, the test was terminated because the heart rate reached 163 beats per minute, 103% of the target heart rate, and the respiratory exchange ratio (RER) value was 1.11 in the cardiopulmonary exercise test, the runner's peak VO2 was determined as 2.57 L/min, the peak VO2 per kilogram was 37 ml/min/kg, and the respiratory threshold was 1.86 L/min (72% of peak VO2). This indicates a fitness level classified as 'good' according to the American Heart Association (AHA) criteria. During the test, no ventilatory restrictions were observed in the runner, and cardiovascular responses were found to be normal. Discussion Age, personal medical history, and family history may influence individuals' susceptibility to adverse medical conditions during ultramarathons. However, many runners can complete prolonged runs without experiencing significant health problems. Runners may need support from a family physician during these

criteria. During the test, no ventilatory restrictions were observed in the runner, and cardiovascular responses were found to be normal. Discussion Age, personal medical history, and family history may influence individuals' susceptibility to adverse medical conditions during ultramarathons. However, many runners can complete prolonged runs without experiencing significant health problems. Runners may need support from a family physician during these activities. Elevated CK levels may indicate muscle damage in multistage and long-distance runs. A study by Jastrzębski et al. (15), found that older runners had elevated levels of CK and LDH compared to younger runners during a 100 km race. Additionally, due to regular training, elite athletes' CK, AST, and ALT levels may be higher than the reference upper limit compared to the general population (16). Statins, beta- blockers, angiotensin-II receptor antagonists, and some psychiatric drugs can also increase CK levels (17). Therefore, it is crucial to explore a history of medication use in cases of high CK levels. In this case, a double increase was observed in CK values measured during the run. After 25 days from the end of this athlete's 800 km run, the CK value was found to be at the upper limit of the normal range (Table 1). In our case, there is no medication that would elevate CK levels. The asymptomatic elevations observed in our case may be related to exercise. Other biochemistry levels were within normal limits. Factors such as consumption of non-steroidal anti-inflammatory drugs (NSAIDs), race pace, runners' morpho-functional characteristics, and hydration-related mistakes are determinants in developing AKI resulting from running in athletes (9). But, in the study by Poussel et al. (18), no significant decrease in glomerular filtration rate was observed in ultramarathon runners not using NSAIDs. Our case has no family history of kidney disease, did not use NSAIDs, and maintained a low pace during the run. Therefore, this athlete had no considerable risk factor for AKI, urea and creatinine levels were within normal ranges (Table 1). However, it is known that NSAIDs are commonly used in ultradistance races (19,20); therefore, runners should be informed of the potential dangers. Monitoring

family history of kidney disease, did not use NSAIDs, and maintained a low pace during the run. Therefore, this athlete had no considerable risk factor for AKI, urea and creatinine levels were within normal ranges (Table 1). However, it is known that NSAIDs are commonly used in ultradistance races (19,20); therefore, runners should be informed of the potential dangers. Monitoring urine volume and color and providing guidance on adequate fluid intake in athletes participating in running activities is essential (21). Additionally, changes in body weight during running can be used as an easy and descriptive marker to assess hydration status. Body weight loss of 3% or less generally does not decrease exercise performance (22). An important issue in running activities is avoiding excessive water consumption while ensuring adequate water intake. Recommending excessive water intake to prevent weight loss or the risk of AKI due to

Yildiz S et al. Health parameters of a 62-year-old athlete during a 27-day ultra-endurance run. Euras J Fam Med 2024;13(4):209-14 213 dehydration may lead to hyperhydration and increase the risk of exercise-related hyponatremia (23). To prevent exercise-associated hyponatremia, it is recommended to consume water in response to thirst, monitor weight loss during the race, and avoid excessive sodium intake (22,24). In our case, sodium levels were within normal limits during the 27 days of 800 km running, and a post-run weight loss of 2.8% indicates no excessive fluid intake. Thus, evaluations of this athlete's appropriate fluid intake and exercise- related hyponatremia showed that optimum conditions occurred during running. Conclusion Supporting these athletes becomes increasingly important as ultramarathon participation rises. Interactions between family physicians and their runners offer a significant opportunity to promote and protect runners' health. Assessing musculoskeletal, renal function and use of medications before running, providing training on NSAID use and hydration, monitoring urine volume and color during running, and monitoring weight may help prevent acute kidney injury and exercise-associated hyponatremia. Moreover, evaluating runners after the race is essential since these adverse conditions may persist post-run. To protect the health of individuals involved in various running disciplines, there is a need to investigate the medical conditions that these runners may encounter and strategies to prevent these conditions. Acknowledgements We wish to thank Family Physician Dr. Hasan Onat for his valuable contributions during the data collection process. References 1. Scheer V. Participation trends of ultra endurance events. Sports Med Arthrosc Rev 2019;27(1):3-7. doi:10.1097/jsa.0000000000000198 2. Scheer V, Basset P, Giovanelli N, Vernillo G, Millet GP, Costa RJS. Defining off-road running: a position statement from the ultra sports science foundation. Int J Sports Med 2020;41(5):275-84. Epub 20200214. doi:10.1055/a-1096-0980 3. Zaryski C, Smith DJ. Training principles and issues for ultra-endurance athletes. Curr Sports Med Rep 2005;4(3):165-70. doi:10.1097/01.csmr.0000306201.49315.73 4. Fariod M, Olher RR, Sousa CV, Scheer V, Cuk I, Nikolaidis PT, et al. Pacing variation in multistage ultramarathons: internet-based cross-sectional study. JMIR Form Res 2023;7:e46650. doi:10.2196/46650 5. Scheer V, Krabak BJ. Musculoskeletal injuries in ultra-endurance running: a scoping review. Front Physiol 2021;12:664071. doi:10.3389/fphys.2021.664071. 6.

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A case study on health parameters of an older athlete during an ultra-endurance run.