Case Reports of the Athletic Heart
Athletes with Coronary Artery Calcifications: A Case Report
Question: What is the next appropriate step?
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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