Alec J Moorman1, Larry S Dean1, Eugene Yang1, Jonathan A Drezner2. 1. Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington. 2. Department of Family Medicine, Sports Medicine Section and UW Medicine Center for Sports Cardiology, University of Washington, Seattle, Washington.
Abstract
CONTEXT: Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes. EVIDENCE ACQUISITION: Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020). STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended. CONCLUSION: We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.
CONTEXT: Limited data are available to guide cardiovascular screening in adult or masters athletes (≥35 years old). This review provides recommendations and the rationale for the cardiovascular risk assessment of older athletes. EVIDENCE ACQUISITION: Review of available clinical guidelines, original investigations, and additional searches across PubMed for articles relevant to cardiovascular screening, risk assessment, and prevention in adult athletes (1990-2020). STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Atherosclerotic coronary artery disease (CAD) is the leading cause of exercise-induced acute coronary syndromes, myocardial infarction, and sudden cardiac death in older athletes. Approximately 50% of adult patients who experience acute coronary syndromes and sudden cardiac arrest do not have prodromal symptoms of myocardial ischemia. The risk of atherosclerotic cardiovascular disease (ASCVD) can be estimated by using existing risk calculators. ASCVD 10-year risk is stratified into 3 categories: low-risk (≤10%), intermediate-risk (between 10% and 20%), and high-risk (≥20%). Coronary artery calcium (CAC) scoring with noncontrast computed tomography provides a noninvasive measure of subclinical CAD. Evidence supports a significant association between elevated CAC and the risk of future cardiovascular events, independent of traditional risk factors or symptoms. Statin therapy is recommended for primary prevention if 10-year ASCVD risk is ≥10% (intermediate- or high-risk patients) or if the Agatston score is >100 or >75th percentile for age and sex. Routine stress testing in asymptomatic, low-risk patients is not recommended. CONCLUSION: We propose a comprehensive risk assessment for older athletes that combines conventional and novel risk factors for ASCVD, a 12-lead resting electrocardiogram, and a CAC score. Available risk calculators provide a 10-year estimate of ASCVD risk allowing for risk stratification and targeted management strategies. CAC scoring can refine risk estimates to improve the selection of patients for initiation or avoidance of pharmacological therapy.
Authors: Michael J Wolk; Steven R Bailey; John U Doherty; Pamela S Douglas; Robert C Hendel; Christopher M Kramer; James K Min; Manesh R Patel; Lisa Rosenbaum; Leslee J Shaw; Raymond F Stainback; Joseph M Allen Journal: J Am Coll Cardiol Date: 2013-12-16 Impact factor: 24.094
Authors: Scott M Grundy; Neil J Stone; Alison L Bailey; Craig Beam; Kim K Birtcher; Roger S Blumenthal; Lynne T Braun; Sarah de Ferranti; Joseph Faiella-Tommasino; Daniel E Forman; Ronald Goldberg; Paul A Heidenreich; Mark A Hlatky; Daniel W Jones; Donald Lloyd-Jones; Nuria Lopez-Pajares; Chiadi E Ndumele; Carl E Orringer; Carmen A Peralta; Joseph J Saseen; Sidney C Smith; Laurence Sperling; Salim S Virani; Joseph Yeboah Journal: Circulation Date: 2018-11-10 Impact factor: 29.690
Authors: Nasir Hussain; Bernard J Gersh; Karina Gonzalez Carta; Nóra Sydó; Francisco Lopez-Jimenez; Stephen L Kopecky; Randal J Thomas; Samuel J Asirvatham; Thomas G Allison Journal: Am J Cardiol Date: 2017-11-13 Impact factor: 2.778
Authors: S Giri; P D Thompson; F J Kiernan; J Clive; D B Fram; J F Mitchel; J A Hirst; R G McKay; D D Waters Journal: JAMA Date: 1999-11-10 Impact factor: 56.272
Authors: Carlijn M van der Aalst; Sabine J A M Denissen; Marleen Vonder; Jan Willem C Gratama; Henk J Adriaansen; Dirkjan Kuijpers; Rozemarijn Vliegenthart; Jeanine E Roeters van Lennep; Pim van der Harst; Richard L Braam; Paul R M van Dijkman; Rykel van Bruggen; Matthijs Oudkerk; Harry J de Koning Journal: Eur Heart J Cardiovasc Imaging Date: 2020-10-20 Impact factor: 6.875
Authors: Emanuele Di Angelantonio; Nadeem Sarwar; Philip Perry; Stephen Kaptoge; Kausik K Ray; Alexander Thompson; Angela M Wood; Sarah Lewington; Naveed Sattar; Chris J Packard; Rory Collins; Simon G Thompson; John Danesh Journal: JAMA Date: 2009-11-11 Impact factor: 56.272
Authors: Barry J Maron; Benjamin D Levine; Reginald L Washington; Aaron L Baggish; Richard J Kovacs; Martin S Maron Journal: J Am Coll Cardiol Date: 2015-11-02 Impact factor: 24.094
Authors: Donna K Arnett; Roger S Blumenthal; Michelle A Albert; Andrew B Buroker; Zachary D Goldberger; Ellen J Hahn; Cheryl Dennison Himmelfarb; Amit Khera; Donald Lloyd-Jones; J William McEvoy; Erin D Michos; Michael D Miedema; Daniel Muñoz; Sidney C Smith; Salim S Virani; Kim A Williams; Joseph Yeboah; Boback Ziaeian Journal: J Am Coll Cardiol Date: 2019-03-17 Impact factor: 24.094