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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: 884
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