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Disease Risk Management
Table 1: American Heart Association Consensus Panel –
reflect lifelong overall exposure to all risk factors, and may overcome the
Recommendations for Pre-participation Screening
limitations of cross-sectional assessment of risk factor burden at one
specific point in time.
Family history
1. Premature sudden death
Current Guidelines for Cardiovascular
2. Heart disease in surviving relatives
Personal history
Risk Stratification in Athletes
3. Heart murmur
To determine the risk of a CV event in presumably healthy marathon runners,
4. Systemic hypertension a simple 12-element CV screening algorithm has been proposed by the
5. Fatigability
AHA
13
(see Table 1). It comprises a detailed personal and family history as well
6. Syncope
as a physical examination including auscultation and blood pressure
7. Exertional dyspnoea
measurements. IOC,
18
ESC
17,19,20
and German
16
guidelines also recommend a
8. Exertional chest pain
routine 12-lead resting electrocardiogram (ECG) as part of the initial
Physical examination
9. Heart murmur*
evaluation. In cases of abnormal findings on initial screening, additional
10. Femoral pulses
tests – including exercise ECG, echocardiography and Holter-ECG – may be
11. Stigmata of Marfan syndrome warranted to obtain further information on CV morphology and function, as
12. Blood pressure measurements prognosis for athletes with diagnosed CAD worsens with the extent of
* Pre-cordial auscultation is recommended in both supine/sitting and standing positions to identify heart disease, LV systolic dysfunction, inducible ischaemia and electrical instability.
32
murmurs consistent with dynamic left ventricular outflow tract obstruction.
The 36th Bethesda Conference was dedicated to establishing eligibility
Figure 1: Difference in Conventional Cardiovascular Risk
Factors in Marathon Runners
recommendations for competitive athletes with cardiovascular
abnormalities. It was recommended that competitive athletes with
60
established CAD (as defined by a history of CAD events, significant
42%
angiographic CAD, angina symptoms, inducible myocardial ischaemia and a
40
coronary artery calcification [CAC] score >100 [see below]) should have their
20
LV function assessed.
32
If exercise testing is considered necessary, it is
recommended to approximate as closely as possible the cardiovascular and
ascular risk factors
0
metabolic demands of the planned competitive event and its training
-20
regime. In marathon runners, this is often difficult to accomplish and cannot
-15% -19% -12% -18%
-40 replicate the CV stress produced by sustained bouts of exercise during
marathons and the required training. Furthermore, strong evidence from
Difference in cardiov versus age-matched controls (%)
-60
-51%
basic and clinical research suggests that regular exercise improves coronary
-80 microvascular function to such a degree that it can compensate for
BMI Smoking Blood LDL-C HDL-C FRS
epicardial atherosclerosis even in advanced stages of the disease.
2,33
pressure
Standard clinical exercise tests may not always help to identify occult CAD
Difference in conventional cardiovascular risk factors in marathon runners compared with age-matched controls
in marathon runners.
32
from the Heinz Nixdorf Recall Study. The values indicated average risk factors in marathon runners. The lower risk
factor burden results in a Framingham risk score that is only half of that seen in age-matched controls from the
unselected general population. ‘Smoking’ indicates ‘ever smoked’. BMI = body mass index; LDL-C = low-density
Risk Factor Burden in Marathon Runners
lipoprotein cholesterol; HDL-C = high-density lipoprotein cholesterol; FRS = Framingham risk score.
Regular physical activity has a beneficial impact on most modifiable CV
groups based on the number of risk factors present.
30
It is argued that risk factors.
34
In normotensive subjects, average resting systolic and
persons at high risk, including those with established CAD or with risk diastolic blood pressures are reduced by 3.4 and 2.4mmHg, respectively,
equivalents, will most likely benefit from intensive risk modification, while with a much greater effect in hypertensive persons.
34
High-density
persons at low risk are generally advised to adhere to a healthy lifestyle lipoprotein (HDL) cholesterol levels can be expected to increase by
and guideline-based treatment of individual risk factors when present. 3.0–4.6%, while triglyceride and LDL-cholesterol concentrations may
However, in persons at intermediate risk there remains a diagnostic gap. decrease by 0.6–3.7% and 0.8–5.0%, respectively.
34–36
Exercise
Further tests such as coronary artery calcium (CAC) scanning,
31
programmes help to maintain smoking cessation
37
and weight loss,
38
and
measuring intima media thickness (IMT), the ankle arm index (AAI) or beneficially affect glucose metabolism in diabetics.
39
In the Marathon
exercise stress testing may be useful in distinguishing individuals who are Study cohort, all established risk factors were improved compared with
at a high risk from those at a low risk,
29
hopefully leaving few at an age-matched controls (see Figure 1). In addition, runners had lower heart
intermediate risk. However, it should be noted that the Framingham risk rates than controls (64.8±10 versus 76.4±11.8 beats per minute,
score does not take into account lifestyle factors such as diet, exercise respectively; p<0.0001) as well as lower high sensitivity C-reactive protein
and body mass index (BMI), all of which are usually favourable in (hs-CRP) levels (0.1±0.2 versus 0.3±0.6mg/dl, respectively; p<0.0001)
marathon runners. Neither does the score reflect a positive family history and leukocyte levels (5.3±1.2 versus 7.1±1.9nl, respectively; p<0.0001).
of CV disease. The extent of atherosclerotic disease burden, autonomic The Framingham risk score in marathon runners (7.0±3.6% in 10 years)
dysfunction, chronic inflammation, lipoprotein subfractions, blood was even lower compared with women of a similar age from the general
thrombogenicity, the myocardial propensity to develop life-threatening population (7.6±4.9% in 10 years).
22,23
These findings suggest that long-
arrhythmias and unmeasurable genetic factors are also not part of the term regular aerobic exercise may improve CV risk factor burden beyond
conventional risk assessment. Direct quantitative measuring of the extent previous observations from controlled prospective studies with follow-up
of the disease – preferably in its early subclinical stages – may better periods of often not more than six to 12 months.
24 EUROPEAN CARDIOLOGY
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