High-intensity, sport-specific cardiac rehabilitation training of a 22-year-old competitive cyclist after spontaneous coronary artery dissection

Abstract

A 22-year-old man with spontaneous coronary artery dissection wanted to assess the feasibility of returning to competitive cycling. He was referred to the cardiac rehabilitation (CR) program at Baylor Hamilton Heart and Vascular Hospital where staff designed a highintensity, sport-specific training program that simulated the movements and forces associated with his goal activity. The program was symptom limited and enabled the patient to train earlier and at a higher intensity than is typically allowed in conventional CR programs. Daily exercise training was customized to match the physical demands of competitive cycling by using a road bike, an indoor bike power trainer, and an interactive indoor-cycling software program. This case illustrates how specialized CR training, tailored to a patient's specific goals, can aid in the return to vigorous physical activity. He completed the high-intensity exercise training program without adverse signs or symptoms.KEYWORDS Cardiac rehabilitation; cycling; spontaneous coronary artery dissection; sport-specific exercise training S pontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute myocardial infarction that tends to affect young, presumably healthy individuals.1 The underlying pathophysiology of SCAD involves tearing or splitting of the coronary artery wall and/or intramural hematoma formation. SCAD resulting in acute coronary events has a high mortality rate and has been described in association with varied pathophysiological stimuli, 2 including intense exercise.3 Because of the association between SCAD and vigorous physical exertion, certain types of postevent exercise, 4 such as competitive racing, 5 are generally not prescribed. We present a case of SCAD in a young man for whom a unique high-intensity training program was developed toward his goal of returning to a pre-event level of competitive cycling. CASE REPORTA 22-year-old male cyclist with attention deficit hyperactivity disorder presented to the Baylor University Medical Center, Dallas, Texas, emergency department with severe (8 out of 10) substernal chest pain. He complained of dyspnea, nausea, and vomiting, as well as pain radiating to his left arm and neck. The pain started while he was cycling at a popular outdoor trail and had resolved by the time he arrived at the hospital. He had been taking lisdexamfetamine for about 5 months. A computed tomography coronary angiogram revealed a dissection within the proximal left anterior descending artery.6 His cardiologist referred him to a cardiac rehabilitation (CR) program at Baylor Heart and Vascular Hospital, Dallas, Texas, that specializes in high-intensity, sport-specific exercise training. 7-11Upon entry to CR, his medications included aspirin, atorvastatin, and carvedilol. When asked about his CR goals, the patient indicated that he wanted to resume competitive cycling but was exceedingly anxious to do so on his own. For this reason, CR staff developed a progressive high-intensity training program consisting of 5...

Spontaneous coronary artery dissection in patients with prior psychophysical stress: a systematic review of case reports and case series

“…Coronary angiography was used as the first diagnostic modality except for eight patients. Among the rest, cardiac computed tomography angiography (CCTA) was either used alone (n = 3) [55, 77,106] or followed by confirmatory angiography (n = 5) [32, 43, 51, 54, 70]. In general, 13 patients were initially misdiagnosed by coronary angiography [15,26,49,56,63,65,72,74,76,84,85,90,96] and subsequently secured a diagnosis of SCAD by either intravascular ultrasound (IVUS) (n = 2), optical coherence tomography (OCT) (n = 3) or repeated angiography (n = 8).…”

“…(continued) Three cases of multivessel SCAD presented with different types of SCAD in each artery support[16, 37,106], and seven patients were advised to abstain from sports[51, 55, 59,88,97,103]..…”

Rethinking Rehabilitation

“…Although not required, testing prior to enrollment in CR may be useful for guiding the exercise prescription, especially in those highly active prior to their SCAD event. Several studies include completion of a CPX before and/or after an exercise regimen, 47,[53][54][55] but there is no consensus as to protocol; 6MWTs have also been used. 54,56 Regardless of the testing method, improvements in functional capacity in the range of 1.5 metabolic equivalents (METs) of task have been observed.…”

“…Not feeling challenged and/or being treated as if they have coronary artery disease may lead to low CR participation rates among patients with SCAD. 58,59 A few case reports address an individualized (1:1) or sports-specific approach for SCAD survivors, 53,55,60 but currently many CR programs may not have sufficient staffing or resources to allow for this level of care.…”

Spontaneous Coronary Artery Dissection: Mechanisms, Diagnosis and Management

“…2 However, case reports have showed excellent outcomes in patients resuming high-intensity competitive sport activity. 90 The current American Heart Association statement recommends that all SCAD survivors should be referred to a cardiac rehabilitation programme. 2 In the absence of robust evidence of the prognostic benefit of cardiac rehabilitation on SCAD, Krittanawong et al demonstrated that cardiac rehabilitation after SCAD is safe and reported physical and emotional benefits in a majority of SCAD survivors.…”