Revista de Medicina Desportiva (English) January 2019 | Page 7
men, in a proportion of 9:1 between
men and women 3 , increasing to a
ratio of 20:1 in the veteran athlete. 4
It is expected that the incidence
increases as the growing number
of middle-age persons or older play
sports, especially extenuating, like
the marathon. While sudden cardiac
death (SCD) on younger athletes is
mainly caused by cardiomyopathies,
electric heart disease and congenital
anomaly of the coronary exit, coro-
nary artery atherosclerosis disease
(CAD) is by far the main cause (>95%)
of SCD on athletes older than 35
years. 3,4
Traditionally it was thought that
the acute coronary events induced
by exercise were the result of athe-
rosclerotic plaque and subsequent
thrombosis. However, recently, a
study on SCD during long distance
races 5 , the absence at the autopsy
of rupture of the coronary plaque
in several victims suggests that
might be a more significant cause
due to serious ischemia because of
the significant demand on athletes
with previous unknown ischemic
coronary disease. For this reason, it
makes sense the early identification
of CAD during the screening of vete-
ran athletes (>35 years of age).
Until now, the traditional scores
of risks for CV, like the Framingham
(FRS) and the one from the European
Society (SCORE), and also the stress
test, have been used to identify high-
-risk athletes for exercise-related
cardiac events. However, these risk
scores and the inclusion of the
stress test have significant limita-
tions because, on one hand, they
underestimate the risk on athletes,
since they were not created for phy-
sical active persons and the low CV
risk score might give a false sensa-
tion of security and, on the other
hand, the stress test could have low
value to detect occult CAD due to its
low sensibility on subjects without
symptoms with low or intermediate
CV risk. 6
The role of the image exams on
the prevention of CV events rela-
ted to sports is discussed since the
beginning of this decade, whereby
the paper by Hélder Dores et col 7
seems to have an important role on
the screening of the asymptomatic
veteran athlete (>40 years of age)
with the angio CT-scan and Calcium
Score (CS), where they refer that
this new image methodology will
be better for the diagnosis of the CV
risk on veteran athletes, and this
observation corroborates the order
investigations. 5,8 There some limita-
tions to this work, because it doesn’t
include athlete women, has a small
sample and, mostly, there isn't any
follow-up in order to know which
athletes had adverse events in the
future. It is the author himself that
indicates on the discussion that the
presence of non-obstructive CAD
on asymptomatic persons is not a
contraindication for physical exer-
cise. So, it will be in the future, with
the follow-up longitudinal studies,
more important to know if physical
exercise will be capable to reduce
the events, namely the fatal ones,
even on the asymptomatic persons,
instead of knowing the severity of
the atherosclerosis.
Recent studies 9 also confirm that
endurance athletes have a supe-
rior CS in relation to the sedentary
people with the same risk profile,
indicating a possible different phy-
siopathological mechanism on the
creation of the plaques on athletes,
suggesting that, although there are
more plaques, they are more cal-
cified and, for that reason, more
stabilized and with a lower risk for
acute coronary syndromes, where
the physical exercise is not malefic
as a consequence.
So, actually 10 it is recommended
that the veteran athletes with CAD,
known or suspected, should do a
stress test as a first line exam to
evaluate athletes/patients willing to
go on sports of competition. If the
maximum stress test comes nor-
mal and if the risk profile is low, the
chance to have a significant CAD is
extremely low and no additional test
is needed, and the subject is allowed
to go on sports of competition, provi-
ded his risk is annually evaluated. If
there is a borderline or an equivocal
test or when the rest EKG is uninter-
pretable (for example, complete left
bundle block), an ischemic image
exam should be done, preferably on
a facility with more experience and
availability (MRI with perfusion or
stress echocardiogram or even myo-
cardial perfusion scintigraphy with
radioisotopes). If there is ischemia,
an angio CT-scan and a CS must be
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