The Athlete With Cardiovascular Disease: CAD and Master Athletes
Care of the Athletic Heart 2019
Dear Sports and Exercise Cardiology Enthusiasts:
Care of the Athletic Heart 2019 (CAH), directed by Matthew Martinez MD, and Jonathan Kim, MD, convened June 20-22 at the American College of Cardiology's Heart House in Washington, DC. The overflow capacity of attendees and number of live streaming participants exceeded 220 in total. In the next few weeks, we will post summaries of key sessions written by cardiology Fellows-in-Training (FIT). Most of them were presenters at CAH, and all are active in the Sports and Exercise Cardiology Section FIT Interest Group.
Thank you to the FITs for all their hard work. We hope you enjoy the summaries.
Eugene H Chung, MD, FACC
Editorial Team Lead, Sports & Exercise Cardiology Clinical Topic Collection
Exercise has long been touted as a means of reducing cardiovascular risk. Although athletes have a lower event rate, they are not immune to coronary disease, even in the masters athlete cohort. Here are five key take-home messages from Dr. Sanjay Sharma's talk.
- Cardiovascular risk: Traditional risk factors including diabetes, hypertension, hyperlipidemia and tobacco should not be overlooked in this population. Age is one nonnegotiable risk factor, and indeed the overwhelming majority of sports-related sudden deaths occur over the age of 40, with the majority of these related to atherosclerotic coronary artery disease (CAD). Studies have shown that sudden cardiac death and myocardial infarction happen more frequently during exertion versus rest.1,2 However, the event rate for active individuals is still significantly lower than those with more sedentary habits.
- Screening: Screening for coronary artery disease in masters athletes should include a detailed history, physical and electrocardiogram.3 When indicated, a maximal exercise stress test can be included for risk stratification. The athletes who require further risk stratification can be difficult to identify when asymptomatic given the low sensitivity and specificity of stress testing in this population.4 Coronary calcium scoring can help further risk stratify intermediate risk patients.
- Coronary artery calcium: Recent studies have shown that coronary artery calcium (CAC) scores are higher in certain masters athletes, particularly males, than age matched controls, which is of unclear significance.5,6 Management of athletes with elevated CAC scores focuses on addressing and treating risk factors, including statin therapy for those with LDL ≥70 mg/dL and CAC ≥100 AU or ≥75th percentile. In those with CAC ≥400 AU, consider an ischemic evaluation.
- Management: In athletes with CAD, as with any patient, one must revascularize if appropriate, mitigate risk and treat with conventional medical therapy.7 It is prudent to risk stratify a few months post-myocardial infarction and then proceed with shared decision-making about return to play. If one is low risk, asymptomatic with normal LV function, normal exercise capacity and no ventricular arrhythmias or inducible myocardial ischemia, then usually the athlete can return to all sports. In the United Kingdom, this low risk category also specifies that coronary stenosis, if present, should be <50%. Those with any abnormal findings or extensive scar on cardiac MRI are considered high risk: restriction to sport with low intensity static and dynamic features should be considered.3 Furthermore, those on dual anti-platelet therapy should be cautioned to avoid contact sports.
- Current controversies: Mechanisms underlying increased CAC in athletes remain uncertain. The pathophysiology of CAC deposition, its composition and the associated risk in sedentary versus active individuals is not fully understood. One hypothesis is that endothelial injury occurs more readily during exercise and this injury may be repaired with calcium deposition. It is unclear from conventional CT imaging if this calcium is deposited in the endothelium, smooth muscle or both. Further research should clarify potential mechanisms and risks due to the finding of increased CAC in athletes.
While atherosclerotic cardiovascular disease is not uncommon even among masters athletes, death from myocardial injury occurs more often in those with less robust habitual exercise routines. Male masters athletes indeed have more calcified plaques compared to controls based on coronary CT scan, but we don't fully understand the significance. It is important to emphasize the role of shared decision-making when considering return to sport after a myocardial infarction. In the sedentary and masters athletes alike, we should aggressively risk stratify and treat known cardiovascular risk factors.
- Mittleman MA, Maclure M, Tofler GH, sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocaridal Infarction Onset Study Investigators. N Engl J Med 1993;329:1677-83.
- Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Mansons JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 2000;343:1355-61.
- Borjesson M, Dellborg M, Niebauer J, et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J 2019;40:13-8.
- van de Sande DA, Hoogeveen A, Hoogsteen J, Kemps HM. The diagnostic accuracy of exercise eletrocardiography in asymptomatic recreational and competitive athletes. Scand J Med Sci Sports 2016;26:214-20.
- Mohlenkamp S, Lehmann N, Breuckmann F, et al. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J 2008;29:1903-10.
- Merghani A, Maestrini V, Rosmini S, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with low atherosclerotic risk profile. Circulation 2017;136:126-37.
- 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.
Clinical Topics: Arrhythmias and Clinical EP, Dyslipidemia, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Nonstatins, Novel Agents, Statins, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging, Hypertension, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging
Keywords: Sports, Coronary Artery Disease, Exercise Test, Risk Factors, Athletes, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Blood Platelets, Cardiovascular Diseases, Physical Exertion, Electrocardiography, Coronary Stenosis, Atherosclerosis, Myocardial Infarction, Tomography, X-Ray Computed, Death, Sudden, Cardiac, Diabetes Mellitus, Hypertension, Arrhythmias, Cardiac, Hyperlipidemias, Magnetic Resonance Imaging, Decision Making, Endothelium
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