Case Reports of the Athletic Heart

Athletes with Coronary Artery Calcifications: A Case Report

Question: What would you do next?

Answer: C
Further risk stratification needed

The patient has already optimized his lifestyle and is exceeding current physical activity guidelines.1 He is asymptomatic without clear evidence of ischemia or acute coronary syndrome, so jumping to invasive coronary angiography for his coronary artery calcifications would not be appropriate at this time. Medical management may be indicated, so his 10-year ASCVD Risk is calculated and found to be borderline at 5.1%. Initiation of a low dose aspirin and a moderate intensity statin therapy are both IIb recommendations and can be considered if other risk-enhancing factors are present.2 He is therefore sent for labs and studies for further risk stratification.

Lipoprotein (a) is elevated at 198 nmol/L, high sensitivity CRP <0.2 mg/L, and hemoglobin A1c is 5.3%. A two-week external rhythm monitor to assess his symptomatic palpitations demonstrated sinus rhythm ranging from 37 bpm to 162 bpm with an average rate of 56 bpm. Patient triggered events on the monitor during episodes of post-exercise palpitations showed brief runs of an irregular supraventricular tachycardia with a maximum rate of 200 bpm and the longest run lasting 14 beats at average rate of 94 bpm. There are rare premature ventricular contractions seen but no ventricular runs. A CT coronary calcium score reveals a total Agatston score of 2085, placing him in the 99th percentile. The distribution shows no calcium in the left main, 461 in the left anterior descending, 347 in the left circumflex, and 1278 in the right coronary artery.

Authors: Deepak Ravi, MD; Timothy Canan, MD, Division of Cardiology, Department of Medicine, University of California, Los Angeles

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