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Recommendations for participation in leisure time or competitive sports in athletes with coronary artery disease
-A Position Statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC)
Mats Borjesson, MD, FESC, Mikael Dellborg, MD, Josef Niebauer, MD, FESC, Andre LaGerche, MD, Christian Schmied, MD, Erik E Solberg, MD, FESC, Martin Halle, MD, Paolo Adami, MD, Alessandro Biffi, MD FESC, Francois Carr, MD, Caselli, Stefano, MD, Michael Papadakis, MD, FESC, Axel Pressler, MD, Hanne Rasmusen, MD, Luis Serratosa, MD, Sanjay Sharma, MD, FESC, Frank van Buuren, MD, and Antonio Pelliccia, MD, FESC.
Corresponding author:
Mats Borjesson, prof, MD, FESC
Center for Health and Performance and Dept of Neuroscience and Physiology, Gteborg University and Sahlgrenska University Hospital, Gteborg, Sweden
Mail: HYPERLINK "mailto:mats.brjesson@telia.com" mats.brjesson@telia.com
Mobile: +46 705 298360
Introduction
This paper presents an update of earlier recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) ADDIN EN.CITE ADDIN EN.CITE.DATA 1 on sports-participation in patients with coronary artery disease (CAD), coronary artery anomalies or spontaneous dissection of the coronary arteries, all entities being associated with myocardial ischemia. Myocardial bridging is also a potential cause of myocardial ischemia and will be discussed.
Since the focus of these recommendations does not lie on the routine work-up of CAD patients in general ADDIN EN.CITE Montalescot201340384038403817Montalescot, G.Sechtem, U.Achenbach, SAndreotti, FArden, CBudaj, ABugiardini, RCrea, FCuisset, TDiMario, CFerreira, JRGersh, B JGitt ,AKHulot ,J-SMarx, NOpie, LHPfisterer, MPrescott, ERuschitzka, FSabate, MSenior, RTaggart, DPvanderWall, EEVrints, CJM2013 ESC guidelines on the management of stable coronary artery diseaseEur Heart JEur Heart J2949-30033420132, but on patients who wish to engage in leisure-time or competitive sports, these patients will be referred to as patient-athletes. Cardiovascular pre-participation screening in athletes to detect CAD lies outside the scope of this paper, and is discussed elsewhere ADDIN EN.CITE ADDIN EN.CITE.DATA 3, 4.
In subjects >35years of age, including athletes, CAD is the main cause of myocardial ischemia ADDIN EN.CITE Adabag201040674067406717Adabag, ASPeterson, GApple, FSTitus, J King, RLuepker, RVEtiology of sudden death in the community: results of anatomical, metabolic and genetic evaluationAm Heart JAm Heart J33-915920105. Major risk factors, in addition to age and sex, include family history of CAD, hypercholesterolemia and smoking, particularly if combined ADDIN EN.CITE Piepoli201640684068406817Piepoli, MFHoes, AWAgewall, SAlbus, CBrotons, CCatapano, ALCooney, MTCorra, UCosyns, BDeaton, CGraham, IHall, MSHobbs, FDRLochen, MLLllgen, HMarques-Vidal, PPerk, JPrescott, ERedon, JRichter, DJSattar, NSmulders, YTiberi, MvanderWorp, HBvanDis, IVerschuren, WMMBinno, S2016 European guidelines on cardiovascular disese prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology amnd Other Socities on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart JEur Heart J2315-813720166. Physical inactivity is an additional risk factor for CAD, and conversely, regular physical training reduces the risk of developing CAD, as well as the risk of sudden cardiac death or arrest (SCD/SCA) during vigorous exertion ADDIN EN.CITE Mittleman199387787787717M A MittlemanM MaclureG H ToflerJ B SherwoodR J GoldbergJ E MullerTriggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exercise. N Engl J MedN Engl J Med1677-8332919937.
On the other hand, observational data indicate that intensive exercise training (beyond 7 times per week or 18 hours of strenuous exercise per week), increases the mortality risk in patients with CAD ADDIN EN.CITE Mons201428512851285117Mons, UHahmann, HBrenner, HA reverese J-shaped association of leisure-time physical activity prognosis in patients with stable coronary heart disease: evidence from a large cohort with repeated measurementsHeartHeart1043-910020148. Nevertheless, data from multiple endurance and non-endurance sporting events with participation demographics suggest that actual incidence of acute events is very low ADDIN EN.CITE ADDIN EN.CITE.DATA 9-11. Thus, according to these observational evidences the benefits of regular physical activity and sport participation outweigh by far the increased risk for coronary events triggered by acute, intensive physical activity.
Myocardial ischemia during exercise is caused by a demand-supply mismatch and may be provoked by an increase in heart rate, blood pressure and workload, such as typically occurs during exercise. Cardiac events during sports are believed to be triggered by neuro-hormonal activation, precipitating plaque rupture ADDIN EN.CITE Thompson200710771077107717P D ThompsonB A FranklinG J BaladyS N BlairD CorradoN A M EstesIIIJ E FultonN F GordonW H HaskellM S LinkB J MaronM A MittlemanA PellicciaN K WengerS N WillichF CostaExercise and acute cardiovascular events. Placing the risks into perspective. A scientific statement from the American heart Association Council on nutrition, physical activity, and metabolism and the Council on Clinical CardiologyCirculationCirculation2358-68115200712, hypercoagulability, endothelial erosion ADDIN EN.CITE Quillard201740584058405817T Quillard G Franck T Mawson E Folco P Libby Mechanisms of erosion of atherosclerotic plaquesCurr Opin LipidolCurr Opin LipidolCurrent opinion in lipidology434-4128201713 and/or to very high intensity exercise, overpassing the threshold of ischemia in patients/athletes with chronic and stable CAD ADDIN EN.CITE Kim201224262426242617J H KimR MalhotraG ChiampasP dHemecourtC TroyanosJ CiancaR N SmithT J WangW O RobertsP D ThompsonA L BaggishCardiac arrest during long-distance running races. Race Associated Cardiac Arrest Event Registry (RACER) Study GroupN Engl J MedN Engl J Med130-4036620129 ADDIN EN.CITE Shaw201240354035403517L J ShawW S WeintraubD J MaronP M HartiganR Hachamovitch J K MinM DadaG B J ManciniS W HayesR A ORourkeJ A SpertusW KostukG Gosselin B R ChaitmanM Knudtson J Friedman P Slomka G Germano E R Bates T K TeoW E BodenD S BermanBaseline stress myocardial perfusion imaging results and outcomes in patients with stable ischemic heart disease randomized to optimal medical therapy with or without percutaneous coronary interventionAm Heart JAm Heart J243-50164201214.
Common symptoms include chest pain (typical or atypical angina), dyspnea, palpitations, light-headedness or syncope, which all are typically effort-related. With regard to the clinical presentation, it should be noted however, that athletes might present with atypical symptoms, such as overall reduction of exercise-capacity, and unusually elevated heart rate during exercise, although they might occasionally be symptom-free, possibly due to improved collateral coronary circulation ADDIN EN.CITE Heaps201140694069406917Heaps, CLParker, JLEffects of exercise training on coronary collateralization and control of collateral resistanceJ Appl PhysiolJ Appl Physiol587-98111201115. Absence of symptoms during effort, regardless the extent of underlying coronary pathology, may likely be associated with a lower risk of ischemia during acute, intense exercise. Indeed, in stable angina the extent of ischemia does not seem to predict clinical long-term outcome ADDIN EN.CITE ADDIN EN.CITE.DATA 14, 16.
During recent years, novel cardiac imaging techniques including coronary artery calcium score (CACS), CT coronary angiography (CTCA) and, to a lesser extent, cardiac magnetic resonance imaging (CMR) have made the diagnosis of subclinical coronary artery disease increasingly possible ADDIN EN.CITE Erbel201040334033403317R Erbel S Mhlenkamp S Moebus A Schmermund N Lehmann A Stang N Dragano D Grnemeyer R Saibel H Klsch M Brcker-Preuss K Mann J Siegrist K-H JckelCoronary trisk stratification, discrimination, and reclassification improvement based on quatification of subclinical coronary atherosclerosis. The Heinz Nixdorf Recall StudyJ Am Coll CardiolJ Am Coll Cardiol1397-40656201017. However, imaging techniques do not provide information relative to the coronary flow and reserve, which represents the key point to assess the risk of SCD/SCA associated with exercise. In this regard, the different methods of stress testing (e.g. cycle ergometry or treadmill testing), stress echocardiography, adenosine or dobutamine stress cardiac MRI or PET/SPECT, play a major role. Exercise testing has the advantage of being widely available, providing also functional information, such as peak- and submaximal exercise capacity, blood pressure response and the capability to detect exercise-induced arrhythmias ADDIN EN.CITE Brjesson200577477477417M BrjessonM DellborgExercise-testing post-MI: still worthwhile in the interventional era?Eur Heart JEur Heart J105-0626200518. However, exercise testing is known to have a low sensitivity, especially in asymptomatic individuals and in less advanced cases of CAD. Maximal exercise effort is often not adequately pursued in the routine clinical practice, whereby potential pathological findings may be missed. Therefore, in the setting of evaluation of competitive athletes with suspected CAD, maximal exercise capacity should be assessed, which is an important prognostic marker by itself ADDIN EN.CITE Shuval201440364036403617K Shuval C E FinleyC E BarlowK P GabrielD LeonardH W Kohl3rdSedentary beavior, cardiorespiratory fitness, physical activity, and cardiometabolic risk in men: the Cooper Center Longitudinal StudyMayo ClinMayo Clin1052-6289201419.
When patient-athletes are assessed for eligibility to competitive sports, it is understood that the patient-athlete should be eligible to participate in sport at very-high intensity level, without any limitation, since during competition maximal exertion may well occur.
A different attitude occurs when advising participation in leisure time and amateur sport, in which a measure of control of the intensity and duration of the exercise load is feasible. Moreover, the specific type of sport ADDIN EN.CITE Pelliccia201740564056405617Pelliccia, AAdami, PEQuattrini, FSqueo, MRCaselli, SVerdile, LMaestrini ,VDiPaolo, F MPisicchio, CCiardo, RSpataro, AAre Olympic athletes free from cardiovascular diseases? Systematic investigation in 2352 participants from Athens 2004 to Sochi 2014Br J Sports MedBr J Sports Med238-4351201720 should additionally be considered, since some are more likely to induce myocardial ischemia than others, in relation to intensity and duration of the event/game (Figure 1). In advising patient-athletes with CAD to engage in competitive sports, we should carefully balance the documented benefits of exercise programs with the potential risk for adverse events. Given the wealth of evidence supporting the benefits of exercise for primary and secondary prevention of CAD, we believe that individuals should be restricted from competitive sport only when a substantial risk of adverse event or disease progression is present.
Indeed, leisure time activity is advised, and should be recommended individually (i.e., exercise prescription), to all individuals with risk factors for, as well as with manifest CAD ADDIN EN.CITE Piepoli201640684068406817Piepoli, MFHoes, AWAgewall, SAlbus, CBrotons, CCatapano, ALCooney, MTCorra, UCosyns, BDeaton, CGraham, IHall, MSHobbs, FDRLochen, MLLllgen, HMarques-Vidal, PPerk, JPrescott, ERedon, JRichter, DJSattar, NSmulders, YTiberi, MvanderWorp, HBvanDis, IVerschuren, WMMBinno, S2016 European guidelines on cardiovascular disese prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology amnd Other Socities on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart JEur Heart J2315-813720166.
Thus, these recommendations aim to encourage regular physical activity including participation in sports and, with reasonable precaution, ensure a high level of safety for all individuals with CAD ADDIN EN.CITE ADDIN EN.CITE.DATA 21. The present document is based on available current evidence, but in most instances because of lack of scientific evidence, also on clinical experience and expert opinion. The available class and level of evidence is given for each recommendation.
1. Coronary artery disease- CAD
Clinically, CAD in a previously healthy individual is typically suspected upon the presence of anginal symptoms, in addition to the traditional risk factors being present ADDIN EN.CITE Genders201140374037403717T S S GendersE W SteyenbergH AlkadhiS LeschkaL Desbiolles K NiemanT W GalemaW B MeijboomN R MolletP J deFeyterF CademartiriE MaffeiM DeweyE ZimmermannM LauleF PuglieseR BarbagalloV SinitsynJ BogaertK GoetschalkU J SchoepfR J RoweJ D SchuijfJ J BaxF R deGraafJ KnuutiS KajanderC A G anMieghemM F L MeijsM J CramerD GopalanG Feuchtner G FriedrichG P KrestinM G M HuninkA clinical prediction rule for the diagnosis of coronary artery disease: validation, updating and extensionEur Heart JEur Heart J1316-3032201122. Symptomatic athletes with clinical suspicion of CAD should be assessed according to established guidelines ADDIN EN.CITE ADDIN EN.CITE.DATA 2, 23 (Figure 2).
Importantly, most athletes with risk factors for and/or underlying CAD may be asymptomatic, as they may be detected during pre-race or pre-competition medical evaluations, or during cardiac screening and/or functional physical capacity testing.
Asymptomatic athletes with absence of clinically evident CAD
CAD evolves gradually with subclinical disease becoming progressively more likely to be detectable over time. Although contentious, there is an increasing tendency to include coronary imaging in screening algorithms. As a result, clinical decision-making regarding asymptomatic coronary disease is encountered with increasing frequency. Therefore, clinical evaluation should include (Figure 2):
-evaluation of functional ischemia,
-assessment of coronary risk factors (with adequate treatment).
Exercise stress testing remains the pivotal test to evaluate the patient-athlete who wishes to enter competitive sports.
In general, if the maximal exercise-test is normal, and CV risk factor profile is low, the presence of relevant CAD is assumed to be unlikely. In this instance, no additional tests are mandatory and no restriction for competitive sports is advised. Risk factor management should be adequate and annual follow-up is recommended.
In case of a borderline or equivocal exercise test result (e.g. ST depression of 0,15mV, not typically ascending ST segment, etc.) as well as in the case of an uninterpretable ECG (pre-existing LBBB or ventricular pacing), we recommend performing an additional stress-test, such as stress-Echo/-MRI/PET/SPECT. This panel advices maximal-exercise SPECT as first diagnostic step in athletes. However, we also acknowledge the option of exercise echocardiography or nuclear perfusion techniques (exercise or pharmacological). The choice of these tests is guided by their diagnostic accuracy, being dependent on local expertise and by their availability.
If the exercise test is positive, preferentially CT or coronary angiogram should be performed to confirm presence and extent of CAD. In case CT shows the presence of significant lesions, according to routine clinical criteria ADDIN EN.CITE ADDIN EN.CITE.DATA 2, 23, the patient-athlete should undergo coronary angiography. It should be noticed that master endurance athlete show a higher degree, and a more diffuse distribution of coronary calcium in the coronary tree, compared to non-athletes at similar low risk-factor level ADDIN EN.CITE Merghani201740634063406317Merghani, VMaestrini, VRosmini, SCox, ATDhutia, HBastiaenen, R.David, SYeo, TJNarain, RMakhotra, APapadakis, MWilson, MGTome, MAifakih, KMoon, JCSharma, SPrevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profileCirculationCirculation126-37136201724. At present, the long-term clinical implications of these findings are debated.
Subsequently, the patient management as well as decision-making regarding sports participation should be made according to the diagnosis of CAD (see patient-athletes with clinically proven CAD; 1.2 below).
Risk factor assessment and treatment should be pursued, as advised in detail in guidelines; there is no evidence that athletes should be treated any differently than non-athletes ADDIN EN.CITE Montalescot201340384038403817Montalescot, G.Sechtem, U.Achenbach, SAndreotti, FArden, CBudaj, ABugiardini, RCrea, FCuisset, TDiMario, CFerreira, JRGersh, B JGitt ,AKHulot ,J-SMarx, NOpie, LHPfisterer, MPrescott, ERuschitzka, FSabate, MSenior, RTaggart, DPvanderWall, EEVrints, CJM2013 ESC guidelines on the management of stable coronary artery diseaseEur Heart JEur Heart J2949-30033420132. In fact, treatments for dyslipidemia and arterial hypertension have comparable efficacy and similar adverse effects, although there is some evidence that statin-associated myalgia may be slightly more common amongst athletes ADDIN EN.CITE Eijsvogels201340474047404717Eijsvogels, T MParker, BAThompson, PDStatin and exercise prescriptionLancetLancet1621381201325.
1.2 Clinically proven CAD
For patient-athletes with proven CAD, as documented by an earlier clinical event, CT-scan or coronary-angiography, advice relative to sport participation should be based on individual assessment (Figure 2). Recommendations on eligibility for competitive sports should primarily be based on:
presence of exercise-induced myocardial ischemia
exercise induced arrhythmia
evidence of myocardial dysfunction
type and level of sport competition
fitness level of the individual patient-athlete
profile of cardiovascular risk factors ADDIN EN.CITE Brjesson201113231323132317M BrjessonA UrhausenE KouidiD DugmoreS SharmaM HalleH HeidbuchelH H BjornstadS GielenA MezzaniD CorradoA PellicciaL VanheesCardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the section of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and RehabilitationEur J Cardiovasc Prev RehabilEur J Cardiovasc Prev Rehabil446-581820113
According to the results of diagnostic testing we recommend to stratify patient-athletes with proven CAD as follows:
Low probability for exercise-induced adverse cardiac events, if all of the following apply:
absence of critical coronary stenoses (i.e., <70%) of major coronary arteries or <50% of left main stem on coronary angiog r a p h y
e j e c t i o n f r a c t i o n e"5 0 % o n e c h o c a r d i o g r a p h y , C M R o r a n g i o g r a p h y ( a n d n o w a l l m o t i o n a b n o r m a l i t i e s )
n o r m a l , a g e - a d j u s t e d e x e r c i s e c a p a c i t y
a b s e n c e o f i n d u c i b l e i s c h e m i a o n m a x i m a l e x e r c i s e t e s t i n g
a b s e n c e o f m a j o r v e n t r i c u l a r t a c h y a r r h y t h m i a s ( i . e . , N on-sustained ventricular tachycardia (NSVT), polymorphic or very frequent ventricular extra beats (VEBs), at rest and during maximal stress testing
High probability for exercise-induced adverse cardiac events, if at least one of the following applies:
presence of at least one critical coronary stenosis of a major coronary artery (>70%) or left main stem (>50%) on coronary angiography
ejection fraction <50% on echocardiography (or other tests)
exercise-induced ischemia (>0.1 mV ST depression (horizontal or
down-sloping (at 80 ms after the J point) in 2 chest leads or ST elevation > 0.1 mV (in a nonQ-wave lead and excluding aortic valve replacement) or new left bundle branch block at low exercise intensity or immediately post-exercise ADDIN EN.CITE Fletcher201340614061406117G F FletcherP A AdesP KligfieldR ArenaG J BaladyV A BittnerL A CokeJ L FlegD E FormanT C GerberM GulatiK MadanJ RhodesP D ThompsonM A WilliamsExercise standards for testing and training: a scientific statement from the American Heart AssociationCirculationCirculation873-934128201326
dyspnea at low exercise intensity (angina equivalent)
relevant ventricular tachyarrhythmias (i.e., Non-sustained ventricular tachycardia (NSVT), polymorphic or very frequent ventricular extra beats (VEBs), at any time,
dizziness or syncope on exertion
high degree of myocardial scarring on CMR imaging
As general consideration, this panel believes that (this paragraph has been moved, but is unchanged):
If ischemia is present during functional testing despite adequate treatment, revascularization may be primarily considered. Specifically, in case the patient-athlete wants to participate in competitive sports, revascularization should be preferred, since during maximal exercise the high myocardial oxygen consumption attained and the neuro-hormonal activation increases the likelihood of myocardial ischemia and cardiac events (N.B.: expert consensus). Furthermore, anti-anginal medications such as beta-blockers may be less well tolerated in athletes.
If despite adequate treatment ischemia cannot be completely resolved, then the patient-athlete should be restricted from competitive sport and advised to enter leisure-time sports activities, which are associated with less physical demands and lower intensity, so that ischemia may more likely be avoided ( ADDIN EN.CITE Niebauer199724752475247517J NiebauerR HambrechtT VelichK HauerC MarburgerB KlbererC WeissE vonHodenbergG SchlierfG SchulerR ZimmermannW KublerAttenuated progression of coronary artery disease after 6 years of multifactorial risk intervention: role of physical activityCirculationCirculation2534-4196199727; figure 1).
If the patient-athlete is going to engage in leisure-time physical activity, revascularization may be not be strictly required ADDIN EN.CITE ADDIN EN.CITE.DATA 27-29, as the evidence supporting revascularization over medical management for stable CAD remains somewhat contentious ADDIN EN.CITE ADDIN EN.CITE.DATA 29-32.
Recommendations:
Patient-athletes with clinically proven CAD and considered to be at low-risk for cardiac events may be selectively advised to participate in competitive sports (Figure 2). However, as a measure of caution due to the high hemodynamic load and possible electrolyte imbalance, restrictions may apply on an individual basis for certain sports with the highest CV demand (such as extreme power and endurance disciplines, see figure 1). Moreover, older patient-athletes with CAD and even low risk profile deserve special attention, and a more cautious advice, as recent studies have shown that the risk of SCD during endurance event (e.g., triathlon) was around 11 times higher in men >60-year old ADDIN EN.CITE Harris201740544054405417Harris, KMCrewswell, LLHaas, TSThomas, TTung, MIsaacson, EGarberich, RFMaron, BJDeath and cardiac arrest in U.S. triathlon participants, 1985 to 2016: a case seriesAnn Intern MedAnn Intern Med529-35167201733 -Level of evidence: Class IIa, level C
Patient-athletes with clinically proven CAD, defined as high risk, should be temporarily restricted from competitive sport and receive appropriate management (Figure 2). As in all patients, also in patient-athletes with CAD and significant ischemia during exercise, anti-ischemic therapy needs to be optimized. In case of continued ischemia, revascularization ought to be performed ADDIN EN.CITE ADDIN EN.CITE.DATA 33, 34. -Level of evidence: Class IIa, level C
After revascularization or after a clinical event, a gradual increase in exercise duration and intensity is recommended during the first months, with careful attention to the development of new symptoms ADDIN EN.CITE Thompson201540554055405517Thompson, PDMyerburg, RJLevine, BDUdelson, JDKovacs, RJEligibility and disqualification recommendations for competivite athletes with cardiovascular abnormalities: Task Force 8: Coronary artery disease. A scientific staement from the American Heart Association and the American College of CardiologyCirculationCirculatione310-314132201535. Provided the patient-athlete is considered as having a low-probability for cardiac events, we recommend a minimum of three months after-PCI, before competitive sports can be resumed. Contact sports should be avoided while the patient-athlete is under dual antiplatelet therapy, because of the risk of bleeding, but may be considered afterwards.
Eligibility assessment should always be combined with advising the patient-athlete on the correct approach to training (e.g., warm-up and cool-down; adequate hydration, awareness of the whether conditions...). Periodical cardiac evaluation, at least on a yearly basis, is advised. The risk risk factors should be properly managed with appropriate pharmacologic and lifestyle modifications, as they may affect the speed of progression of the atherosclerotic disease.
2. Non-CAD related myocardial ischemia
2.1. Congenital coronary artery anomalies, CAA
In this section, we refer to the CAA-anomalies that include origins of the coronary vessel from the wrong sinus and anomalous origin from the pulmonary artery. These CAA are associated with SCA/SD, often in young, asymptomatic individuals ADDIN EN.CITE Hill201424862486248617S F HillM N SheppardA silent cause of sudden cardiac death especially in sport: congenital coronary artery anomaliesBr J Sports MedBr J Sports Med1151-648201436. The incidence in the normal population is not fully known, but approximated to 0.5-1% ADDIN EN.CITE Yamanaka199040624062406217Yamanaka, OHobbs, RECoronary artery anomalies in 126,595 patients undergoing coronary arteriographyCathet Cardiovasc DiagnCathet Cardiovasc Diagn28-4021199037.
Resting ECG, echocardiography and even exercise testing frequently are not able to show any abnormal findings. Chest pain or syncope on exertion, or even SCD, may be the first symptoms of CAA ADDIN EN.CITE Basso200010141014101417C BassoB J MaronD CorradoG ThieneClinical profile of congenital coronary artery anomalies with origin from the wrong sinus leading to sudden death in young competitive athletesJ Am Coll CardiolJ Am Coll Cardiol1493-50135200038. Mechanisms leading to SCD likely include (repeated bursts of) ischemia with consequent increase of fibrous tissue and a proclivity to develop ventricular arrhythmia during exercise. Ischemia may be the consequence of compression of the anomalous vessel coursing between the aorta and the pulmonary artery and/or due to the acute angled take-off from the aorta. In case of anomalous origin of the left main CA from the pulmonary trunk, there is a chronic ischemic condition, being exacerbated by exercise.
Multi-slice contrast-enhanced computed tomography (CT) or CT coronary angiography are primary diagnostic tools, while in clinical practice (preparticipation cardiac screening), echocardiography may reveal or raise the suspicion of an abnormal origin of the coronary artery. In view of limiting radiation exposure, in particular to adolescent patients, cardiac MRI may also be an option.
Eligibility for competitive sport is based on the anatomical type of CAA, as well as on the presence of ischemia.
Specifically, in CAA originating from the wrong sinus, with acute angled take-off from the aorta and anomalous coursing between the aorta and the pulmonary artery, the risk for SCA/SD is believed to be the highest. Strong consideration should be given to surgical correction of such an anomaly in symptomatic patients. Prior to successful correction, participation in high-intensity sport is discouraged. -Level of evidence: Class II level C
Traditionally, CAAs without inter-arterial course have been considered having a low risk. In the absence of ischemia and arrhythmias on stress testing or symptoms (dizziness, fainting or syncope), there is no indication for surgical repair or treatment. At present, because of a lack of solid data, a prudent approach is recommended and advising for competitive sports participation is based on individual evaluation (N.B.: expert consensus). -Level of evidence: Class III, level C
In case of previous surgical correction and lack of persistent, inducible ischemia, all competitive sports are allowed. -Level of evidence: Class III level C.
In other types of CAA, such as anomalous origin of the circumflex artery from the right sinus, it is relevant to confirm the absence of inducible ischemia and, in this case, no restriction exist regarding competitive sport participation. -Level of evidence: Class IIa level C
2.2 Coronary artery dissection
There is no reliable data on the incidence of spontaneous coronary artery dissection (SCAD). However, it is easily overlooked and may account for up to 4% of acute coronary syndromes ADDIN EN.CITE Nishiguchi201640484048404817Nishiguchi, TTanaka, AOzaki, YTaruya, A, Fukuda, S, Taguchi, H, Iwaguro, TUeno, S Okumoto, Y Akasaka, TPrevalence of spontaneous coronary artery disseaction in patients with acute coronary syndromeEur H J Acute Cardiovasc CareEur H J Acute Cardiovasc Care263-7052016Rashid201640494049404917Rashid, HNWong, DTWijesekera, HGutman, SJ Shanmugam, VB Gulati, R Malaipan, Y Meredith, IT Psaltis, PJIncidence and characterisation of spontaneous coronary artery dissection as a cause of acute coronary syndrome- a single-centre Australian experienceInt J CardiolInt J Cardiol336-8202201639, 40. SCAD has been associated with strenuous exertion in males and with pregnancy in females, with a relatively high rate of recurrence within 4 years (17%) ADDIN EN.CITE Tweet201240504050405017Tweet, MSHayes, SNPitta, SR Simari, RDLerman, ALennon, RJ Gersh, BJ Khambatta, SBest, PJ Rihal, CS Gulati, RClinical features, management, and prognosis of spontaneous coronary artery dissectionCirculationCirculation579-88126201241.
Treatment for SCAD is similarly uncertain with a range of options including percutaneous coronary intervention, bypass surgery and/ or medical therapy with dual anti-platelet therapy or anticoagulation. There is no evidence comparing the efficacy and risks of these strategies. Similarly, the duration of medical therapies is empirical. However, frequently SCAD is seen as a result of coronary plaque formation, which emphasizes the need for optimal risk factors management. Beyond these recommendations there is an absence of guidelines on SCAD in general as well as patient/athletes ADDIN EN.CITE Kalaga200740514051405117Kalaga, RVMalik, AThompson, PDExercise-related spontaneous coronary artery dissection: case report ands literature reviewMed Sci Sports ExercMed Sci Sports Exerc1218-2039200742.
Athletes with a previous episode of dissection have to be informed that the recurrence rate is probable and that strenuous exertion is a potential trigger. This panel believes that individuals with SCAD should be discouraged from competitive sport participation. In these instances, leisure time activity is advised, and should be recommended individually (i.e., exercise prescription). Class III level C.
2.3 Myocardial bridging
Myocardial bridging (MB) may be occasionally discovered at imaging testing required to solve the ambiguity of an abnormal exercise ECG. Similar to CAA, MB should be suspected in athletes who present with exertional angina or syncope.
Evaluation of the individuals with MB is aimed primarily at assessing the presence of inducible ischemia. Recently, it has been shown that the percentage of arterial compression in MB may be directly relate to the atherosclerotic burden, proximal to the MB ADDIN EN.CITE Yamada201640654065406517Yamada, RTremmel, JATanaka, SLin, SKobayashi, YHollak, MBYock, PGFitzgerald, PJSchnittger, IHonda, YFunctional versus anatomic assessment of myocardial bridging by intravascular ultrasound: impact of artrial compression on proximal atherosclerotic plaqueJ Am Heart AssocJ Am Heart AssocJournal of the American Heart Associatione0017355201643. Observational studies have shown that in patients without obstructive CAD on coronary CT, the presence of an intramural course of a coronary artery was not associated with a clinical worsening in 5-year follow-up ADDIN EN.CITE Dimitru-Leen201740644064406417Dimitru-Leen, ACvanRosendahl, ARSmit, JMvanElst, TvanGeloven, NMaanitty, TJukema, JWDelgado, VScholte, AJHASaraste, AKnuuti, JBax, JJLong-term prognosis of patients with intramural course of coronary arteries assessed with CT angiographyJ Am Coll CardiolJ Am Coll Cardiol1451-810201744. Thus, MB without other underlying diseases (e.g. hypertrophic cardiomyopathy) and with no evidence of inducible myocardial ischemia/CAD, seems to have a good prognosis.
In the absence of inducible effort related ischemia or complex ventricular tachyarrhythmias (i.e., NSVT, polymorphic or very frequent VEBs, induced by exercise), there is little evidence for exercise-induced harm. Therefore, asymptomatic patient-athletes with myocardial bridging can participate in all competitive and leisure-time sports ADDIN EN.CITE Iqbal201540434043404317Iqbal, JZhang, Y-JHolmes, DRMorice, M-CMack, MJKappetein, APFeldman, TStahle, EEscaned, JBanning, APGunn, JPColombo, ASteyerberg, EWMohr, FWSerruys, PWOptimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-upCirculationCirculation1269-77131201534. Level of evidence: Class IIa level C.
Conversely, in those with evidence of ischemia or symptoms, beta-blockers are the first line therapy. If this therapy fails, then surgical repair may be considered, whereas stenting is discouraged ADDIN EN.CITE Cerrato201740524052405217Cerrato, EBarbero, UDAscenzo, FTaha, SBiondi-Zoccai, GOmede, PBianco, MEchavarria-Pinto, MEscaned, JGaita, FVarbella, FWhat is the optimal treatment for symptomatic patients with isolated coronary myocardial bridge? A systematic review and pooled analysisJ Cardiovasc MedJ Cardiovasc Med758-70182017Tarantini201640534053405317Tarantini, GMigliore, FCademartini, FFraccaro, CIiiceto, SLeft anterior descending artery myocardial bridging: a clinical approachJ Am Coll CardiolJ Am Coll Cardiol2887-9968201645, 46. These individuals should be restricted from sport competition, and should be properly advised regarding leisure-time activities. Level of evidence: Class IIa level
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Given the net benefits of exercise, we recommend that patient-athletes with asymptomatic coronary disease defined as CAD with no evidence of inducible ischemia on functional tests, may be advised for participation in all types of exercise programs, including competitive sports, based on an individual careful evaluation.
Effective risk factor management according to guidelines is mandatory ADDIN EN.CITE Montalescot201340384038403817Montalescot, G.Sechtem, U.Achenbach, SAndreotti, FArden, CBudaj, ABugiardini, RCrea, FCuisset, TDiMario, CFerreira, JRGersh, B JGitt ,AKHulot ,J-SMarx, NOpie, LHPfisterer, MPrescott, ERuschitzka, FSabate, MSenior, RTaggart, DPvanderWall, EEVrints, CJM2013 ESC guidelines on the management of stable coronary artery diseaseEur Heart JEur Heart J2949-30033420132.
The patient/athlete should periodically be reassessed regarding risk profile and progression/regression of CAD - Level of evidence: IIa, evidence C.
IIn summary, patient-athletes with clinically proven CAD, considered as having a low probability for events (anatomically as well as functionally), are eligible for most sports, also at competitive level based on individual evaluation.
However, exceptions apply for high-intensity sports (intensive power and endurance sport) and patient-athletes of older age (> 60 years).
Level of evidence: IIa; evidence C
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