Case Reports of the Athletic Heart
Athletes with Coronary Artery Calcifications: A Case Report
Question: What is the next appropriate step?
Answer: B
Exercise stress testing
Given his significant coronary calcium burden in the 99th
percentile, a high dose statin is more appropriate. A beta blocker is certainly
reasonable but requires an informed discussion with athletes as it can be
tolerated poorly with a reduction in exercise heart rate and capacity. CT
coronary angiography could be useful to evaluate plaque morphology, but can be
challenging in the setting of a high calcium burden with reduced sensitivity and
positive predictive value due to extensive blooming artifact. Invasive
angiography would be preferred if the patient had chest pain, decreased systolic
function, ischemia on stress testing, or ventricular arrhythmias, which have not
been demonstrated in this patient.
He agreed to start taking aspirin 81 mg daily and high intensity statin therapy
with rosuvastatin 20 mg daily. He then underwent cardiopulmonary exercise
testing with stress echocardiography imaging. He exercised on a recumbent
bicycle with ramp protocol, reaching a peak work rate of 262 W, heart rate of
163 bpm (101% MPHR), and a VO2 Max of 41.1 ml/kg/min (141% predicted).
Anaerobic threshold was calculated at 206 W using the V-slope method and
occurred at a heart rate of 146 bpm. He experienced no symptoms or arrhythmias
during or after peak exercise and had no evidence of ischemia by
electrocardiogram or echocardiography. Repeat lipid panel on statin therapy
showed a reduction in total cholesterol to 168 mg/dL, HDL 88 mg/dL, LDL 69 mg/dL,
and triglycerides 56 mg/dL. He is cleared to continue his current level of
exercise, predominantly in the aerobic range based on his CPET test results. He
is given instructions on symptoms to monitor for during exercise, as well as
precautions for when to seek emergency care. He has done well so far with no
statin-induced myopathy symptoms, ischemic symptoms or events.
Authors: Deepak Ravi, MD;
Timothy Canan, MD, Division of Cardiology, Department of Medicine, University of California, Los Angeles
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