I respectfully wish to challenge the conclusion by Rao et al that the jury is still out on the potential adverse cardiovascular consequences of endurance exercise.1,2 The finding in a 10-year registry of US road races that marathon running is a significant risk factor for cardiac arrest in middle-aged males is the most robust evidence to date that vigorous exercise can trigger such events.3,4 Pre-mature cardiovascular morbidity and mortality, as also reported in US ironman triathletes,5 mandates an evidence-based response to address this paradoxical complication of endurance sports participation.