Assessment and Management of Atherosclerosis in the Athletic Patient

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Abstract

Many patients and physicians correctly associate physical activity with reduced cardiovascular morbidity and mortality. Vigorous physical exertion is paradoxically associated with a transient increase in the risk of cardiovascular events and sudden cardiac death. This review extrapolates data from the general population to the management of athletes with symptoms suspicious for coronary artery disease or with prior cardiac events. A history to elicit an athlete's concerns and symptoms combined with a physical examination should guide the decision for preparticipation exercise testing for athletes without prior cardiac events. Athletes with established coronary artery disease should receive aggressive secondary prevention regimens, with special attention to adverse effects that may be unique to this group. There may be benefit in taking time away from competitive athletics to allow for stabilization of coronary artery disease with cholesterol-lowering therapy and, therefore, reduction of future risk. Exercise testing is important for defining risk before the return to participation for athletes who have sustained a cardiac event. Many athletes will ultimately be able to return to full participation provided they have received aggressive therapy and understand the residual risk associated with vigorous physical exertion in the setting of coronary artery disease.

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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    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.

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