Atherosclerosis is a progressive disease that can manifest early in life.¹ By middle-age, a substantial part of the general population may have underlying, often subclinical coronary artery disease (CAD). Masters athletes (age >35 years) are not immune to this burden. In fact, CAD is the leading cause of sudden cardiac death (SCD) in Masters athletes irrespective of possessing greater cardiorespiratory fitness than sedentary counterparts.² As the active population continues to grow and encompass a wider age range, so does the need for evidence-based cardiovascular risk assessments and management strategies. To address this need, the European Society of Cardiology (ESC) published guidelines for sports cardiology and exercise recommendations in patients with cardiovascular disease (CVD).³ This document provides a comprehensive guide for risk stratification, testing, and management to inform exercise recommendations and cardiovascular care in the athletic population. In this expert review, we focus on recommendations for Masters athletes with stable CAD in relation to 1) the 2020 ESC guidelines, 2) the 2015 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, 3) stable ischemia data from the general population, and 4) shared decision-making.

Masters athletes with sudden cardiac arrest or death related to underlying CAD are often asymptomatic and presumably healthy. Consequently, they are often thought to be protected from traditional cardiovascular risk factors (e.g. hypertension and hyperlipidemia) by their high levels of fitness. However, with the main risk factors for CAD being age and sex, a substantial number of Masters and veteran athletes may have underlying, undiagnosed CAD. For this reason, the ESC suggests inclusion of both sport intensity and individualized cardiovascular risk when performing an athlete's cardiovascular assessment, specifically citing use of the Systematic Coronary Risk Evaluation (SCORE) system. SCORE incorporates age, sex, smoking status, cholesterol, and blood pressure to estimate the risk of a future cardiovascular event (similar to the ACC/AHA pooled cohort Atherosclerotic CVD risk equation).^3,4 The ESC publication also provides algorithms for the assessment of Masters athletes with known CAD. Importantly, when assessing sports eligibility in Masters athletes with CAD, both anatomical and functional data should be obtained and reviewed.

According to the ESC guidelines, Masters athletes with a SCORE <5% (a SCORE of 5% equates to a 5% risk of a fatal cardiovascular event in the next 10 years) are considered low risk, and if asymptomatic and physically active, they may proceed with unrestricted sports participation in all sporting intensities. Those with a SCORE ≥5% are advised to undergo additional evaluation, which includes a maximal-effort stress test. In Masters athletes with established CAD and inducible ischemia on maximal-effort stress testing, further evaluation on clinical grounds is advocated and sporting restrictions may apply. Athletes with low-risk coronary lesions, no symptoms, preserved left ventricular ejection fraction (LVEF), and no arrhythmias during maximal-effort exercise testing may generally participate in any intensity exercise program (with the possible exception of extreme sports, such as triathlon competition, on an individual basis). In athletes, it is of utmost importance to perform a truly maximal-effort exercise test (or equivalent stress test), to reveal any arrhythmias and/or ischemia at maximal intensity activity. Those with high-risk coronary lesions are advised to undergo revascularization prior to being considered for sport. If revascularization is unsuccessful or if the athlete remains symptomatic despite optimal medical therapy, the maximum intensity exercise recommended is moderate leisure activity with restriction from competitive athletics. Individuals may return to full intensity sport after revascularization if they have a normal maximal exercise test (no arrhythmia or ischemia), normal LVEF, and are symptom free, with the possible exceptions described above. Older patients (>60 years old), however, even with normal testing, may need to decrease their intensity of sport on a case-by-case basis given the age-associated increased risk of adverse events during exercise.³

The ACC/AHA guidelines provide recommendations for cardiovascular evaluation and sport eligibility in athletes with known CAD.⁵ Similar to the ESC guidelines, aggressive risk factor modification, caution regarding full clearance for higher risk patients (LVEF <50%, ischemia or arrhythmia during maximal exercise testing), maximal-effort exercise testing for risk stratification, and the importance of shared decision-making were highlighted. In contrast to ESC, the ACC/AHA guidelines do not include recommendations for cardiovascular risk stratification in asymptomatic athletes with cardiovascular risk factors but no known CAD. Further comparisons are listed in Table 1.

Table 1: Comparison of ESC and ACC/AHA Guidelines for Management of Chronic Coronary Syndromes in the Athlete

	ESC (2020)	ACC/AHA (2015)
Chronic coronary syndrome with revascularization	Considered high risk for CVD events the first 12 months post-revascularization, especially post-ACS. After that time, then may proceed^ if normal testing.*+	For ACS or any revascularization, wait at least 3 months, may proceed^ if normal testing*, Consider waiting up to 2 years for full return to athletic competition.
Stable angina with known CAD	Not recommended to participate in sport given the presence of symptoms.	Given the presence of symptoms, only may proceed with low dynamic and low to moderate static demands.
Asymptomatic but inducible ischemia on maximally provocative testing	Invasive coronary angiogram and revascularization if high risk lesion. If revascularization is performed, follow recommendations above, if not revascularized see below.	May proceed only with activities characterized by low dynamic and low to moderate static demands.
High risk coronary artery disease unable to be revascularized	If symptoms and risk factors are optimized then may proceed with skill competitive sport and low to moderate intensity exercise.3	May proceed only with activities characterized by low dynamic and low to moderate static demands.
Coronary calcium with no ischemia on provocative testing/asymptomatic/clinically concealed atherosclerotic CAD	If participate in intensive exercise, should undergo annual maximal stress testing or functional imaging. If normal, then may proceed.^	If LVEF >50% and no electrical instability then may proceed.^

In general, the indications for invasive therapy in athletes are the same as in the general population, i.e. revascularization for high-risk individuals.³ However, in individuals with stable CAD (chronic coronary syndrome), debate remains with respect to timing of revascularization. The ISCHEMIA trial enrolled over 5,000 patients with moderate or severe ischemia and randomized them to either revascularization or medical therapy, showing no significant difference in mortality over approximately 3 years; however, symptoms and quality of life improved for those in the revascularization arm.⁶ Similar to data taken from Hambrecht et al.,⁷ in ORBITA, 230 patients with ischemic symptoms, at least one severe coronary lesion, and on optimal medical management were randomized to revascularization versus sham-control and showed no differences in exercise time or frequency of angina.⁸ Notably excluded from both trials were those with significant left main stenosis or reduced LVEF, populations in which revascularization is rarely disputed. Both ISCHEMIA and ORBITA evaluated older, more sedentary populations with more comorbidities than the usual athletic population, albeit patients were exercising at least 150 minutes per week at moderate intensity in ISCHEMIA. When extrapolated to athletes, sporting activity is not recommended if athletes are symptomatic.³ For athletes wishing to pursue higher sporting intensities, for which the ISCHEMIA data are not applicable, it is suggested to evaluate for ischemia or arrhythmia during maximal-effort exercise testing to further guide exercise recommendations.³ Revascularization may be favored in athletes involved in higher intensity activities (ex. high static (weightlifting), mixed power and endurance (soccer), high endurance (cycling)) as a means to resolve myocardial ischemia. In addition, a truly maximal-effort exercise test is not always achieved in these patients. Further research studies are required to guide management of the Masters athlete with CAD.

While cardiorespiratory fitness is associated with improved prognosis, this does not mitigate the risks of exercise, particularly in an older population. High intensity sports may increase the risk for SCD by means of plaque rupture, demand ischemia, or ventricular arrhythmias from prior scar. As a result, shared decision-making with the athlete is paramount,⁹ whereby the risks, benefits, and athlete's wishes lend to a decision ultimately made by the athlete.^3,5

There is an increasing need for prospective studies to further understand cardiovascular risk and management strategies for the Masters athlete. As suggested by the recent ESC guidelines, these studies should help narrow the evidence gap for optimal risk stratification, screening for, and treatment of atherosclerotic CAD.³ Ultimately, physical activity remains beneficial to the athlete, and recommendations can be tailored to address intrinsic risks to the athlete during sport.

References

1. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics — 2020 update: a report from the American Heart Association. Circulation 2020;141:e139–e596.
2. Parker MW, Thompson PD. Assessment and management of atherosclerosis in the athletic patient. Prog Cardiovasc Dis 2012;54:416–22.
3. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: the task force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). Eur Heart J 2020;Aug 29:[Epub ahead of print].
4. Karmali KN, Goff DC Jr, Ning H, Lloyd-Jones DM. A systematic examination of the 2013 ACC/AHA pooled cohort risk assessment tool for atherosclerotic cardiovascular disease. J Am Coll Cardiol 2014;64:959–68.
5. Thompson PD, Myerburg RJ, Levine BD, Udelson JE, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 8: coronary artery disease: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2406–11.
6. Maron DJ, Hochman JS, Reynolds HR, et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med 2020;382:1395–1407.
7. Hambrecht R, Walther C, Mobius-Winkler S, et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation 2004;109:1371–78.
8. Al-Lamee R, Thompson D, Dehbi H-M, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet 2018;391:31–40.
9. Baggish AL, Ackerman MJ, Lampert R. Competitive sport participation among athletes with heart disease: a call for a paradigm shift in decision making. Circulation 2017;136:1569–71.
10. Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 1: classification of sports: dynamic, static, and impact: a scientific statement from the American Heart Association and American College of Cariology. J Am Coll Cardiol 2015;66:2350-55.

Clinical Topics: Dyslipidemia, Sports and Exercise Cardiology, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Sports and Exercise and ECG and Stress Testing, Chronic Angina

Keywords: Sports, Athletes, ESC Congress, ESC20, Coronary Artery Disease, Exercise Test, Angina, Stable, Risk Factors, Cardiovascular Diseases, Calcium, American Heart Association, Blood Pressure, Hyperlipidemias, Stroke Volume, Quality of Life, Constriction, Pathologic

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