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 PÓS-GRADUAÇÕES FORMAÇÃO CONTÍNUA ENSINO PRESENCIAL OU À DISTÂNCIA CANDIDATURAS: 10 DEZ 2018 A 15 JAN 2019 MEDICINA DO FUTEBOL 3,5 ECTS | 28 horas Comissão Científica: Prof. Doutor Francisco Rocha Gonçalves Prof. Doutor José Carlos Noronha Prof. Doutor João Brito Destinatários: Médicos com pós-graduação ou especialidade em medicina desportiva Horário: 3ª feiras das 18h às 22h I 12 março a 21 maio 2019 Valor: 350€ MEDICINA DO FUTEBOL Mais informações medicinadesportiva.med.up.pt E: [email protected] T: 22 04 26 922 Revista de Medicina Desportiva informa january 2019 · 5