NYC Marathon Death Puts Rhabdomyolysis Risk Factors in Focus

Rhabdomyolysis, a rare but potentially fatal breakdown of skeletal muscle, is the reported cause of death of a 24-year-old runner who collapsed about 2 miles from the finish of her first New York City Marathon on November 1, according to CNN.¹

Rachel Apa, of Lewisberry, Pennsylvania, played Division I field hockey at Bucknell University. A bystander performed CPR and race staff used a defibrillator, but paramedics were unable to save her. Her father told The New York Times that the cause was rhabdomyolysis, and the city medical examiner's office said it is still investigating. Apa's health history, training regimen, and family medical history remain unclear.

Marathon deaths are extremely rare, and deaths from rhabdomyolysis are rarer still, Jonathan Kim, founding director of Emory Sports Cardiology, who was not involved in the case, told CNN. The most common cause of sudden cardiac arrest during a marathon is myocardial infarction, he noted. Milder rhabdomyolysis is common in distance runners but usually goes undetected.

Record Heat Coincided With a 2022 Spike in Marathon Cases

A study published in April in Nephron reviewed charts from 4 New York City hospitals near the finish line for the 2017 to 2023 marathons; the 2020 race was canceled.² The 2022 race was the hottest since the marathon moved to November in 1986, with a peak heat index of 24.5 °C (about 76 °F). That year produced 24 cases of post-marathon rhabdomyolysis, compared with 15 across the other 5 races combined. Race-day heat index correlated strongly with case counts across the 6 races (r = 0.93).

Race day in 2022 was also 5.6°C (about 10°F) warmer than the prior 14-day average, the largest jump in the study period, which the authors said may reflect a lack of heat acclimatization. Of the 24 runners, 20 were male, and their mean age was 32.2 years; 21 arrived with a neurological complaint such as loss of consciousness. Only 1 required dialysis. He sought care 2 days after the race and was the only patient who had taken naproxen, although the authors noted he may have needed the analgesic because his case was already more severe.

Running generates substantial heat in working muscles, and the body's main task is shedding it, Douglas Farrell, a Mount Sinai nephrologist and coauthor of the study, told CNN.¹ In humid conditions, sweat doesn't evaporate to cool the body, heat speeds muscle breakdown, and dehydration compounds the problem. Temperatures at this year's race were milder, in the mid-60s.

Dehydration, Illness, Drugs, and Genetics Add to Risk

Jessica Tomazic, a sports and exercise medicine physician at Cleveland Clinic, told Yahoo Health that risk usually reflects a combination of factors, including dehydration, unaccustomed heat, exercising while sick, genetic conditions such as sickle cell disease, recent alcohol or drug use, a history of heat illness or rhabdomyolysis, or a family history of rhabdomyolysis.³ The condition is also more common among men, people who smoke, and people with obesity. Statins can also contribute in rare cases when the dose is too high for an individual patient, David Mariuma, a nephrologist at Stony Brook Medicine, told Yahoo Health.

Intense workouts such as CrossFit, spinning, and high-intensity interval training classes have also been linked to cases, and Harvard Health Publishing advises extra caution for people starting a new routine or returning after a period of inactivity.⁴ Beyond exertion, causes include medication adverse effects, alcohol use, drug overdose, infections, and trauma or crush injuries.

Exertional rhabdomyolysis (ERM) accounted for 47% of an estimated 26,000 annual US rhabdomyolysis cases in one report cited by a 2016 review, although other studies have found lower shares.⁵ The review's authors noted that repeated episodes, particularly those more severe than the exercise would explain, should raise suspicion of an underlying genetic muscle disease.

NSAIDs and Dehydration, Not CK Levels, Tied to Kidney Injury

A 2024 study in JAMA Network Open examined 200 patients hospitalized with ERM at Kaiser Permanente Northern California from 2009 to 2019. Of these, 8.5% developed acute kidney injury (AKI), and none died.⁶ Creatine kinase (CK) levels were not associated with AKI. Preadmission use of nonsteroidal anti-inflammatory drugs (NSAIDs) was 64.7% vs 21.9% (P < .001), as was dehydration (52.9% vs 4.9%; P < .001).

The authors estimated that eliminating both factors could prevent 92.6% (95% CI, 85.7%-96.1%) of AKI cases in this population and favored acetaminophen over NSAIDs for exercise-related muscle pain. The study was retrospective, and the small number of AKI cases ruled out multivariable analysis. Patients with significant hyperthermia were excluded, and the authors acknowledged possible ascertainment bias, since patients with higher creatinine levels were more likely to be asked about NSAID use and dehydration.

References

1. A 24-year-old running the NYC marathon collapsed 2 miles from the finish line and died. CNN. November 4, 2026. Accessed November 4, 2026. https://www.cnn.com/2026/11/04/health/rhabdomyolysis-rachel-apa-nyc-marathon-death
2. Rosenstock JL, Farrell DR, Coca SG, et al. Rhabdomyolysis and acute kidney injury after the New York City Marathon. Nephron. 2026;150(9):583-590. doi:10.1159/000552131
3. Rahhal N. A rare condition killed a 24-year-old first-time NYC Marathon runner. Its warning signs can be easy to miss. Yahoo Health. November 4, 2026. Accessed November 4, 2026. https://health.yahoo.com/conditions/article/a-rare-condition-killed-a-24-year-old-first-time-nyc-marathon-runner-its-warning-signs-can-be-easy-to-miss-014419439.html
4. Rhabdo: A rare but serious complication of... exercise. Harvard Health Publishing. January 11, 2018. Updated October 27, 2020. Accessed November 4, 2026. https://www.harvardhealth.org/blog/rhabdo-a-rare-but-serious-complication-of-exercise-2018011113059
5. Scalco RS, Snoeck M, Quinlivan R, et al. Exertional rhabdomyolysis: physiological response or manifestation of an underlying myopathy? BMJ Open Sport Exerc Med. 2016;2(1):e000151. doi:10.1136/bmjsem-2016-000151
6. Sabouri AH, Yurgionas B, Khorasani S, et al. Acute kidney injury in hospitalized patients with exertional rhabdomyolysis. JAMA Netw Open. 2024;7(8):e2427464. doi:10.1001/jamanetworkopen.2024.27464