A 24-year-old woman from Lewisberry, Pennsylvania, collapsed during the New York City Marathon on Sunday and later died at a hospital, New York police say. Rachel Apa was just a couple miles short of the finish, reports BritPanorama.
Deaths during marathons are extremely rare, experts say, even as more people run these grueling 26.2-mile races.
The city medical examiner’s office said Tuesday that it is still investigating Apa’s death. Her father, Steve Apa, told the New York Times that the cause was rhabdomyolysis, also known as rhabdo, a rare condition in which skeletal muscle quickly breaks down and dies, poisoning the body. It can damage the kidneys, cause life-threatening heart problems, or trigger total organ failure.
When Apa collapsed, a bystander performed CPR and race staff used a defibrillator. Paramedics took Apa to the hospital, but were unable to save her.
Rhabdomyolysis and heat
Dr. Doug Farrell, a nephrologist at Mount Sinai who was not involved in the case, said rhabdo is rare, but he has seen cases at the New York City Marathon before.
In a study published in April, Farrell documented a dramatic increase in rhabdo cases at the 2022 New York City Marathon. Doctors treated 24 marathoners for rhabdo that year, compared with the three or four they usually see in the race.
The difference appeared to be high heat and humidity, Farrell said.
In 2022, the heat index reached more than 76 degrees, making it the hottest New York City Marathon since the race moved to November in 1986. Marathon day also was much hotter than the two weeks before, so runners were not as acclimated to the temperature, Farrell said.
Temperatures on Sunday were milder, hovering in the mid-60s.
Heat can hurt or slow marathoners because it makes sweating less effective.
“When you run, your muscles generate a lot of heat. Your body’s main job is to get rid of it,” Farrell said. Some marathoners’ core body temperatures can exceed 104 degrees. In hot, humid conditions, sweat doesn’t evaporate and cool the body. Heat also causes faster muscle breakdown. Dehydration can compound the problem.
Rhabdo symptoms can blend in with the normal discomfort of a long race, he said.
Early symptoms can include exhaustion, weakness, nausea, vomiting, and muscle aches. Marathoners whom Farrell has seen with rhabdo often sought care after they passed out or became delirious during a race.
Deaths during marathons are rare
Dr. Jonathan Kim, founding director of Emory Sports Cardiology, said deaths during marathons are extremely rare, and deaths from rhabdo “would be really, really rare.”
Kim, who did not work on Apa’s case, co-authored two large studies of 23 years of death data from US half- and full marathons.
“This death is extremely tragic,” he said. “A young woman dying running a marathon is not common.”
Kim said the most common cause of sudden cardiac arrest in a marathon is myocardial infarction, “your colloquial heart attack,” not rhabdo.
For younger runners, the second most common cause of death from cardiac arrest is “unexplained,” he said, “even after an exhaustive cardiac workup.”
Milder cases of rhabdo often occur among distance runners because muscle breaks down during exercise. If someone played a football game and then had their blood checked for muscle enzymes, Kim said, a test would spot them, but these cases typically go undetected.
Kim has watched interest in running marathons grow since he began studying marathon death data. Sunday’s race broke the world record for the largest marathon in history, with 61,146 finishers.
Nearly 30 million people ran in races from 2010 to 2023, yet runners’ chance of dying from sudden cardiac arrest fell by half, and the survival rate for people who go into cardiac arrest while running is close to 70%, he said.
“The only thing that rivals 70% would be your casinos, your airports, your high schools that have AEDs,” he said. “Compared to your standard out-of-hospital sudden cardiac arrest survival rate, that is like 10%.”
What athletes need to know
Kim urged anyone training for a marathon to watch for signs of heart problems, including chest tightness, lightheadedness, shortness of breath, and a racing heart.
Kim advised runners to talk with their doctor before signing up for a marathon, especially if they have cardiac risk factors such as a family history of heart attack, a history of smoking, or high cholesterol.
“You just need to make sure your traditional risk factors are addressed and discussed,” Kim said.
Apa’s health history, training regimen, and family medical history remain unclear.
This was Apa’s first marathon. She played Division I field hockey for Bucknell University, where she graduated in 2024.
Apa said she ran the New York Marathon to raise money for Parkinson’s disease in honor of her grandfather, who died from it in 2022. On her marathon fundraising page, she wrote that he “taught me to stay active, push my limits, and embrace challenges, shaping my love for sports and movement.”
The ongoing investigations will likely yield more insights into this tragic incident and its implications for marathon safety.
