The risk of exercise-related events.

It must be emphasized that even athletes identified as

being at mildly increased risk and permitted to participate in

low dynamic and low/moderate static competitive sports

(classes IA and IIA) cannot be assured that such participation

will not increase the risk of cardiac events because it is

probable that any exercise transiently poses some increased

exercise risk once CAD is established.

CORONARY ARTERY VASOSPASM

Coronary artery vasospasm classically presents as rest angina

associated with ST-segment elevation, but can be provoked

by physical exertion on rare occasions (18). Vasospasm is an

uncommon cause of chest pain that is evident in 2% to 3%

of patients presenting with chest pain undergoing coronary

angiography (19). Vasospasm is most frequently observed at

coronary sites damaged by atherosclerosis (20), but a substantial

cohort may have angiographically normal coronary

arteries or minimal angiographic luminal narrowing (18,19).

A vasospastic contribution to ischemia should be suspected

when there is marked variation in the exercise threshold for

angina (18), and when there is evidence of myocardial

ischemia with little or no coronary luminal narrowing.

Presently, no widely accepted noninvasive test exists for

eliciting and quantifying vasospastic angina in the setting of

nonobstructive or mildly obstructive coronary arteries. The

occurrence of ST-segment elevation during exercise testing

appears to correlate with the degree of disease activity (i.e.,

those with more frequent episodes of angina will more likely

have a positive test) (21). Provocative testing with

ergonovine-related substances during coronary arteriography

is rarely used (22), but remains the only test recommended

in current practice guidelines (23). However, forced

hyperventilation testing, particularly when combined with

nuclear perfusion imaging, may be a useful noninvasive test

not requiring the administration of ergonovine (24). The

risk associated with participation in sports for athletes with

coronary artery spasm is not known, but we recommend a

cautious approach to patients with documented coronary

vasospasm until the risk of physical exertion for these

patients is better defined.

Recommendations:

Athletes with CAD as previously defined and clinically

Important coronary artery vasospasm should follow the

Evaluation and risk stratification approach delineated

For athletes with coronary atherosclerosis.

Athletes with coronary vasospasm documented at rest

Or with exercise and angiographically normal coronary

Arteries or without evidence of arterial plaquing should

Be restricted to low-intensity competitive sports (class

IA). This restriction should be re-evaluated at least

Annually because some patients with coronary vasospasm

Date: 2016-03-03; view: 872