Assessment and Management of Atherosclerosis in the Athletic Patient
Section snippets
Definitions and scope of the problem
Exercise-related cardiac events are generally defined as those occurring during or within 1 hour after vigorous physical exertion.8 Whereas a variety of cardiac conditions are associated with exercise-related events in the young, CAD is the predominant cause of cardiac events in adults, variably defined as older than 30, 35, or 40 years.9
Vigorous physical exertion is typically defined as exercise requiring 6 metabolic equivalents (METs) or more. Six METS is approximately equal to the energy
Preparticipation screening
Asymptomatic athletes may seek a physician's advice regarding exercise because clearance is required before a specific event or because of personal concern about exercise-related events. An effective evaluation requires a history and a physical examination to detect possible cardiac risk factors such as hypertension, corneal arcus,16 vascular bruits,17 and cardiac murmurs. The history should inquire why the patient sought medical attention and, specifically, if subtle symptoms prompted the
Evaluation of symptomatic athletes
Symptoms such as chest discomfort, dyspnea, or decreased exercise tolerance should be evaluated in athletes in a similar fashion to other patients. Indeed, many victims of exertion-related sudden cardiac death reported possibly cardiac symptoms within a week of their demise.24, 25 Such symptoms are often nonspecific, but coaches, trainers, and athletes should be encouraged to take such symptoms seriously and seek medical evaluation promptly. Our personal experience investigating such events
General management of athletes with established CAD
Athletes may be diagnosed with CAD because of an acute event or because atherosclerotic disease is detected by a variety of increasing popular imaging techniques such as coronary artery calcification imaging. Prevention of a subsequent atherosclerotic event is the goal of therapy for both groups, so that both groups require platelet inhibition, blood pressure control, aggressive lipid management, and exercise advice. The risk of a subsequent event is probably greater in those athletes who have
Return to participation after a clinical event
Return to vigorous activity after a CAD event is often wrought with anxiety. This is especially true if the event was related to exertion, but even individuals who have been revascularized for stable angina often wonder whether they can safely participate and compete in sports. Return to participation in vigorous exercise or competitive sport hinges on 3 issues: rehabilitation after an event, risk stratification for recurrent events, and timing of return, if appropriate.
Graded, exercise-based
Conclusion
Habitual physical exercise confers protection from CAD. Paradoxically, vigorous physical exertion can trigger atherosclerotic events in susceptible individuals. Athletes older than 40 years, as well as individuals older than 40 years about to commence a vigorous exercise program, should be evaluated for and counseled about the potential risks of vigorous exertion and competitive sport. In most cases, the risk to asymptomatic individuals without prior atherosclerotic disease is small. However,
Statement of Conflict of Interest
All authors declare that there are no conflicts of interest.
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Cited by (16)
Coronary artery disease in athletes: An adverse effect of intense exercise?
2018, Revista Portuguesa de CardiologiaCitation Excerpt :SCD or acute myocardial infarction may be the first clinical presentation of CAD. The rupture of non-obstructive coronary plaques is the most common pathophysiological mechanism involved, which explains the previous absence of symptoms such as angina, usually present in individuals with obstructive CAD.9,20,21 Superficial plaque erosion and intraplaque hemorrhage are other mechanisms associated with coronary plaque instability, but ischemia due to an imbalance between oxygen supply and demand has also been described as one of the main causes of acute exercise-related cardiac arrest.20
Exercise Training In Athletes With Heart Disease
2017, Progress in Cardiovascular DiseasesCitation Excerpt :Consequently, vigorous exercise is defined in most studies as exercise requiring ≥6 metabolic equivalents (METS) with 1 MET equaling the energy expenditure at seated rest. This is the definition of “vigorous” used in most studies of exercise-related events, but lower levels of energy expenditure are “vigorous” and may require near maximal effort in unfit and older individuals.10 Vigorous exercise acutely, albeit transiently, increases the risk of CVD events in previously healthy people with occult, and in patients with diagnosed, CVD.
Managing Cardiovascular Disease in Sport and Athletes
2017, Encyclopedia of Cardiovascular Research and MedicineContraindications to sports participation. Spanish Society of Sports Medicine (SEMED) Consensus Document. Version 2023
2023, Archivos de Medicina del DeporteCardiovascular Evaluation and Treatment in the Endurance Athlete
2023, Endurance Sports Medicine: A Clinical Guide, Second Edition
Statement of Conflict of Interest: see page 421.
Dr Thompson reports receiving research grants from the National Institutes of Health, GlaxoSmithKline, Anthera, B. Braun, Genomas, Roche, Aventis, Novartis, and Furiex; serving as a consultant for Astra Zeneca, Furiex, Regeneron, Merck, Takeda, Roche, Genomas, Abbott, Lupin, Runners World, Genzyme, Sanofi, Pfizer, and GlaxoSmithKline; receiving speaker honoraria from Merck, Pfizer, Abbott, Astra Zeneca, GlaxoSmithKline, and Kowa: owing stock in Zoll, General Electric, JA Wiley Publishing, Zimmer, J&J, Sanofi-Aventis, and Abbott; and serving as a medical legal consultant on cardiac complications of exercise, statin myopathy, tobacco, ezetimibe, and nonsteroidals. Dr Parker does not have any conflicts of interest to report.