Controversies in exertional heat stroke diagnosis, prevention, and treatment

J Appl Physiol (1985). 2019 Nov 1;127(5):1338-1348. doi: 10.1152/japplphysiol.00452.2019. Epub 2019 Sep 23.


During the past several decades, the incidence of exertional heat stroke (EHS) has increased dramatically. Despite an improved understanding of this syndrome, numerous controversies still exist within the scientific and health professions regarding diagnosis, pathophysiology, risk factors, treatment, and return to physical activity. This review examines the following eight controversies: 1) reliance on core temperature for diagnosing and assessing severity of EHS; 2) hypothalamic damage induces heat stroke and this mediates "thermoregulatory failure" during the immediate recovery period; 3) EHS is a predictable condition primarily resulting from overwhelming heat stress; 4) heat-induced endotoxemia mediates systemic inflammatory response syndrome in all EHS cases; 5) nonsteroidal anti-inflammatory drugs for EHS prevention; 6) EHS shares similar mechanisms with malignant hyperthermia; 7) cooling to a specific body core temperature during treatment for EHS; and 8) return to physical activity based on physiological responses to a single-exercise heat tolerance test. In this review, we present and discuss the origins and the evidence for each controversy and propose next steps to resolve the misconception.

Keywords: cooling; endotoxin; exercise; heat strain; heat stress; serious heat illness.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Anti-Inflammatory Agents, Non-Steroidal / pharmacology
  • Anti-Inflammatory Agents, Non-Steroidal / therapeutic use
  • Body Temperature / drug effects
  • Body Temperature / physiology*
  • Body Temperature Regulation / physiology
  • Cryotherapy / methods
  • Exercise / physiology*
  • Heat Stroke / diagnosis*
  • Heat Stroke / physiopathology
  • Heat Stroke / prevention & control*
  • Humans
  • Physical Exertion / drug effects
  • Physical Exertion / physiology*
  • Risk Factors


  • Anti-Inflammatory Agents, Non-Steroidal