Cardiac imaging to detect coronary artery disease in athletes aged 35 years and older. A scoping review

Abstract

Sudden cardiac death (SCD) is a devastating event in athletes. Screening efforts that were first directed at athletes younger than 35 years are now focusing on the rapidly growing group of older sportspersons. Athletes aged ≥35 years have a 10-fold increased risk of exercise-related cardiac arrest, mostly due to coronary artery disease (CAD). Although cardiac imaging is pivotal in identifying CAD, the role of imaging modalities in screening asymptomatic older sportspersons remains unclear. We performed a scoping review to identify the role of cardiac imaging to detect CAD in older sportspersons and to identify gaps in the existing literature. We searched MEDLINE, EMBASE and the Cochrane library for studies reporting data on cardiac imaging of CAD in sportspersons ≥35 years. The systematic search yielded 1737 articles, and 14 were included in this scoping review. Imaging modalities included two echocardiography, one unenhanced computed tomography (CT) for coronary artery calcium scoring (CACS), three CACS and contrast-enhanced CT angiography (CCTA), two CACS and cardiac magnetic resonance (CMR), one CCTA with CMR and echocardiography, two CCTA, two CMR, and one myocardial perfusion imaging article. The low number of relevant articles and the selection bias introduced by studying specific groups, like veteran marathon runners, indicate the need for future research. Cardiac CT (CACS and CCTA) probably has the highest potential for pre-participation screening, with high diagnostic value to detect CAD and low radiation dose. However, currently there is insufficient evidence for incorporating routine cardiac imaging in the pre-participation screening of asymptomatic sportspersons over 35 years.

Prevalence of Myocardial Fibrosis in Intensive Endurance Training Athletes: A Systematic Review and Meta-Analysis

“…However, high-intensity endurance training could also have adverse potential effects on the heart, such as electrophysiological abnormalities (5) and elevated cardiac markers, including creatine kinase-MB, troponin T and NT-pro brain natriuretic peptide (2). Braber et al (6) indicated that high-intensity endurance training maybe associated with accelerated progression of coronary atherosclerosis and that coronary heart disease remained the leading cause of death for high-intensity endurance athletes over the age of 35. MF is a condition involving the significant increase of collagen volume in myocardial tissue, which results from myocardial tissue injury caused by myocardial ischemia (hypoxia), inflammation and hypertension overload (7). Specific types of MF are associated with ventricular arrhythmia and adverse cardiac events.…”

“…However, high-intensity endurance training could also have adverse potential effects on the heart, such as electrophysiological abnormalities ( 5 ) and elevated cardiac markers, including creatine kinase-MB, troponin T and NT-pro brain natriuretic peptide ( 2 ). Braber et al ( 6 ) indicated that high-intensity endurance training maybe associated with accelerated progression of coronary atherosclerosis and that coronary heart disease remained the leading cause of death for high-intensity endurance athletes over the age of 35.…”

Highly increased Troponin I levels following high-intensity endurance cycling may detect subclinical coronary artery disease in presumably healthy leisure sport cyclists: The North Sea Race Endurance Exercise Study (NEEDED) 2013

“…In order to achieve a heart rate < 65, short acting beta-blocking agents are used when appropriate. A meta-analysis found that cardiac death or MI occurred in 0.04 % of subjects with no CAD on CCTA, as compared with 1.29 % in subjects with non-obstructive CAD and 6.53 % of subjects with obstructive lesions(166).Echocardiography alone has limited value in identification of CAD, but is an important imaging modality for assessing structural cardiac abnormalities(163).CMR allows for excellent assessment of cardiac function and of LGE without exposure to radiation(163). CMR angiography for anatomical assessment of the coronary arteries is a novel tool with the advantage of no radiation exposure.…”

“…CMR angiography for anatomical assessment of the coronary arteries is a novel tool with the advantage of no radiation exposure. This method however, still offers limited visualization of the coronary arteries, and is currently most used in research(163,165).Invasive coronary angiography is not a first-line test in low-risk subjects due to the higher risk of complications as compared with non-invasive imaging modalities. It uses intravenous contrast and exposes the patient to radiation (2-7 mS) (6).…”

Endurance exercise and myocardial injury

“…Recently, several groups have reported a prevalence of coronary artery disease (CAD) of 40-63% in master athletes. [10][11][12] We have reported elevated post-exercise cTn values following strenuous exercise in asymptomatic subjects with occult CAD. 6 Subjects included in the present study were 50-74 years of age.…”