Athletes’ Hearts Also Require Careful Scrutiny, New Review Suggests

Fitness doesn’t make people immune to atherosclerosis, but what to do with the finding in asymptomatic patients is uncertain.

Athletes’ Hearts Also Require Careful Scrutiny, New Review Suggests

Exercise improves cardiovascular health overall, but studies have also drawn a link between intense amounts of endurance activity in athletes and an increased lifetime risk of coronary atherosclerosis—this counterintuitive association deserves more scrutiny, according to authors of a new review paper.

Long considered to be immune from cardiovascular disease, athletes have been subject to increasing interest given reports of arrhythmias and coronary artery disease seen in those who participate in lots of exercise, lead author Guido Claessen, MD, PhD (UHasselt, Belgium), told TCTMD.

The underlying mechanisms driving these relationships are uncertain, as is how to move forward with treatment, he continued. “We are a little bit at odds with this discrepancy in findings, and physicians are often puzzled [with] what to do with these findings if they are encountered in clinical practice.”

While there is no established causal link between intense exercise and CAD, Claessen advised clinicians to always approach these patients with an eye toward prevention, including potentially cholesterol-lowering drugs and aggressive monitoring.

How to proceed with these patients can be tricky, especially if they are asymptomatic. Commenting on the paper for TCTMD, Sanjay Sharma, MD (St George’s, University of London, England), said: “When evaluating endurance athletes, the prevailing recommendation is that asymptomatic individuals without established risk factors may not require further assessment. However, the lack of symptoms in many athletes who have suffered myocardial infarction underscores the importance of developing strategies for early identification of those at risk.”

Looking at All Risk Factors

For the paper, published online this month in the European Heart Journal, Claessen and colleagues reviewed the available evidence in the field. Studies such as MASTER@HEART, which showed a higher burden of atherosclerotic plaque in endurance athletes compared with healthy controls, and MARC-2, which showed more intense levels of exercise correlate with increased amounts of coronary calcification in men, have suggested there is reason for concern.

“Whilst the risk of CV events has not been shown to rise with athletic activity, the potential for CAD should not be overlooked as it is the leading cause of sudden cardiac death in athletes > 35 years of age (ie, ‘Masters athletes’),” the authors write. “Evaluating both traditional and nontraditional risk factors for CAD is the most important part of preparticipation evaluation in Masters athletes.”

Claessen and colleagues provide an overview of both traditional (age, sex, arterial hypertension, dyslipidemia, impaired glucose metabolism, tobacco use, and family history of CAD) and nontraditional risk factors (dietary macronutrient intake, inflammation, mineral perturbations, and training characteristics) to help clinicians guide their evaluations of these patients.

Additionally, they provide suggestions as to what methods of risk stratification should be used. For example, the authors say that CT should not be used in patients without risk factors or symptoms, but a functional evaluation could be worthwhile in symptomatic patients as well as in asymptomatic patients with a high plaque burden.

While shared decision-making is always recommended, the authors write that physicians should work closely with these individuals to make a plan for lifestyle changes, especially if it involves reducing the amount or intensity of exercise, as well as pharmacological therapy.

Some big questions remain in this space, Claessen acknowledged. He would like to see randomized trials test interventions to identify the ideal preventive therapies for athletes, especially those with evidence of CAD. It is imperative to know not only if certain medications would lower the risk of events over time, but also whether they are “tolerated in the athletic population,” Claessen said, adding that these studies will need to follow the patients long-term.

Also, he added, many of the studies in this space have been exclusively conducted in men, so more study is needed into the effects of high-volume endurance activity in female athletes.

Greater Awareness

Former marathoner Paul Thompson, MD (Hartford Hospital, CT), who has been conducting research in this space for over a decade, told TCTMD he is happy to see the topic of CAD in athletes getting more attention as many clinicians tend to be “surprised” by these findings.

“I think it needs more awareness,” he said. “It freaks a lot of people out when they find that they have all this calcium in their coronary arteries, and it’s not just calcium, it’s actually atherosclerosis.”

When taking care of such patients, Thompson said the first thing he does is reassure them. “I say: ‘This is something that we found. You don’t have any symptoms, yet.’ I don’t necessarily do a coronary angiogram on them or something to look at their arteries. But what I do, unequivocally, is I rule out that they may have hyperparathyroidism because hyperparathyroidism can cause [calcium] deposits.”

The totality of evidence in this space “underlines the necessity of awareness among healthcare providers that lifelong exercise does not guarantee immunity from atherosclerosis,” Sharma stressed.

The key issues moving forward will be for researchers to better understand the cause of atherosclerotic plaque in athletes and how much it increases their risk, according to Thompson. “The third thing is how should it best be treated,” he said. “The unfortunate thing of finding this in athletes is that a lot of people will probably get unnecessary procedures because that’s what happens. We make money when we do things. So, we do things.”

Sources
Disclosures
  • Claessen, Thompson, and Sharma report no relevant conflicts of interest.

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