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Marathon running enjoys an astonishing popularity. Because of the enormous number of applicants, it is quite difficult to get a starting place for one of the marathon races in Berlin, London, or New York. Almost every European city appears to have its own marathon race in the months between April and October. Regularly, out of the tens of thousands of runners, one or two succumb to an acute coronary syndrome or sudden arrhythmias.

It is quite evident that the extreme exertion of a marathon race, as mentally rewarding as it may be, offers little benefit in terms of health and longevity. Indeed, in clinically healthy runners, markers of cardiac injury are elevated after a race.1,2 An inverse relationship between myocardial injury and the amount of training for the race has been described, with the greatest amount of injury incurred by runners with the least training mileage.2 However, the clinical relevance of acute post-race elevations in markers of myocardial injury remains open. There is little evidence to suggest permanent cardiac damage in healthy runners, but the issue is complex. With increasingly sophisticated biomarkers and imaging methods to measure cardiac damage—what is a healthy runner?

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