Prevalence of Subclinical Coronary Artery Disease in Middle-Aged, Male Marathon Runners Detected by Cardiac CT

Abstract

Purpose: To evaluate the prevalence of coronary artery disease (CAD) in middle-aged, male marathon runners using coronary dual source CT angiography (DSCTA).

Materials and Methods: 50 male marathon runners older than 45 years (mean age: 52.7, standard deviation: 5.9 years, range: 45 to 67 years) received DSCTA including calcium scoring (CS) in addition to standard pre-participation screening. Based on standard risk factors, the risk for coronary events was calculated using the PROCAM score. Coronary status was defined using the following system: 1. absence of CAD (CS zero, no coronary plaques) 2. mild coronary atherosclerosis (CS > 0, coronary plaques with luminal narrowing < 50 %), 3. moderate coronary atherosclerosis (CS > 0, luminal narrowing > 50 %), 4. significant CAD (CS > 0, luminal narrowing > 75 %).

Results: The mean PROCAM score was 1.85 % (standard deviation = 1.56, range 0.39 to 8.47 %). 26/50 marathon runners had no atherosclerosis. 1 of the remaining 24 participants had significant CAD, 3 had moderate coronary atherosclerosis and 20 had mild coronary atherosclerosis. Treadmill exercise testing was unremarkable in terms of myocardial ischemia in all participants. Age, systolic blood pressure, personal minimum time, family history of cardiovascular disease and PROCAM score were factors associated with an increased risk for coronary atherosclerosis.

Conclusion: Coronary atherosclerosis can be detected in almost 50 % of male marathon runners aged older than 45 years. In 24 % of the participants plaques were located in the proximal coronary system. However, only a minority of these persons have obstructive CAD. As expected, treadmill exercise testing failed to detect these persons that possibly have a higher risk for coronary events.

Key points:

• Coronary atherosclerosis can be detected in ~50 % of male marathon runners > 45 years

• Only a minority of these persons have obstructive CAD

• Treadmill exercise testing failed to detect these persons

• Cardiac CT might help to identify athletes with elevated risk for coronary events, especially in persons with a family history of coronary artery disease

Citation Format:

• Tsiflikas I, Thomas C, Fallmann C et al. Prevalence of Subclinical Coronary Artery Disease in Middle-Aged, Male Marathon Runners Detected by Cardiac CT. Fortschr Röntgenstr 2015; 187: 561 – 568

Zusammenfassung

Ziel: Ziel der Studie war die Evaluierung der Prävalenz der KHK bei männlichen Marathonläufern mittleren Alters mittels Dual Source cCTA (DSCTA).

Material und Methoden: 50 Marathonläufer (52,7 ± 5,9 Jahre) wurden zusätzlich zur sportmedizinischen Routinediagnostik mittels DSCTA einschließlich Calcium-Scoring (CS) untersucht. Das CS wurde bei allen Personen im high-pitch-Modus (hpDSCTA), die CTA bei 21 Personen im hpDSCTA und 29 Personen im sequentiellen „step-and-shot“-Modus (sDSCTA) durchgeführt. Die effektive Dosis (ED) wurde für beide Scanverfahren bestimmt. Der Risikofaktor für koronare Ereignisse wurde basierend auf Standardrisikofaktoren mittels des PROCAM-Scores berechnet. Der Koronarstatus wurde wie folgt klassifiziert: 1. keine KHK (CS = 0, keine Koronarplaques), 2. milde Koronarsklerose (CS> 0, Stenose < 50 %), 3. moderate Koronarsklerose (CS > 0, Stenose > 50 %) 4. signifikante KHK (CS > 0, Stenose > 75 %).

Ergebnisse: Der mediane PROCAM-Score betrug 1,85 ± 1,56 %. 26 von 50 Marathonläufern hatten keine KHK. 1 Person hatte eine signifikante KHK, 3 Personen eine moderate sowie 20 eine milde Koronarsklerose. Die Laufband-Ergometrie konnte bei keinem Sportler Koronarischämien nachweisen. Als Faktoren für ein erhöhtes KHK-Risiko konnten Alter, Blutdruck, persönliche Mindestzeit, familiäre Anamnese und der PROCAM-Score identifiziert werden. Die mediane ED für die DSCTA lag bei 1,259 ± 0,542 mSv. Bei der hpDSCTA war die ED im Vergleich zur sDSCTA signifikant niedriger (0,762 vs. 1,618 mSv, p < 0,0001).

Schlussfolgerung: Bei fast 50 % der asymptomatischen Marathonläufer über 45 Jahren kann mittels cCTA eine Koronarsklerose nachgewiesen werden. Bei 24 % dieser Probanden waren die Plaques in den proximalen Abschnitten der Koronararterien lokalisiert. Tatsächlich leidet jedoch nur ein kleiner Anteil dieser Personen an einer obstruktiven KHK.Die Laufband-Ergometrie kann wie erwartet diese Risikopersonen für koronare Ereignisse nicht erkennen.

Kernaussagen:

• Koronarsklerose bei ~50 % männlicher Marathonläufer > 45 Jahre

• Nur ein kleiner Teil dieser Personen leidet an einer obstruktiven KHK

• Auf dem Laufbandergometer können diese Risikopersonen nicht erkannt werden

• Kardio-CT mögliche Hilfe bei der Detektion der Athleten mit erhöhtem koronaren Risiko, insbesondere bei familiärem Risikoprofil

Key words

cardiac - CT - CT angiography

• References

• 1 Fletcher GF, Balady G, Blair SN et al. Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation 1996; 94: 857-862
• 2 Corrado D, Schmied C, Basso C et al. Risk of sports: do we need a pre-participation screening for competitive and leisure athletes?. Eur Heart J 2011; 32: 934-944
• 3 Maron BJ, Thompson PD, Ackerman MJ et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007; 115: 1643-1455
• 4 Corrado D, Pelliccia A, Bjornstad HH et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005; 26: 516-524
• 5 Borjesson M, Urhausen A, Kouidi E et al. Cardiovascular evaluation of middle-aged/ senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil 2011; 18: 446-458
• 6 Maron BJ, Shirani J, Poliac LC et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996; 276: 199-204
• 7 Corrado D, Drezner J, Basso C et al. Strategies for the prevention of sudden cardiac death during sports. Eur J Cardiovasc Prev Rehabil 2011; 18: 197-208
• 8 Lloyd-Jones D, Adams RJ, Brown TM et al. Heart disease and stroke statistics – 2010 update: a report from the American Heart Association. Circulation 2010; 121: e46-e215
• 9 Rosamond W, Flegal K, Furie K et al. Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008; 117: e25-e146
• 10 Siscovick DS, Ekelund LG, Johnson JL et al. Sensitivity of exercise electrocardiography for acute cardiac events during moderate and strenuous physical activity. The Lipid Research Clinics Coronary Primary Prevention Trial. Arch Intern Med 1991; 151: 325-330
• 11 Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300 (24) 1350-1358
• 12 Schroeder S, Achenbach S, Bengel F et al. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J 2008; 29: 531-556
• 13 Achenbach S, Barkhausen J, Beer M et al. Consensus recommendations of the German Radiology Society (DRG), the German Cardiac Society (DGK) and the German Society for Pediatric Cardiology (DGPK) on the use of cardiac imaging with computed tomography and magnetic resonance imaging. Fortschr Röntgenstr 2012; 184: 345-368
• 14 Assmann G, Cullen P, Schulte H. Simple scoring scheme for calculating the risk of acute coronary events based on the 10-year follow-up of the prospective cardiovascular Munster (PROCAM) study. Circulation 2002; 105: 310-315
• 15 Rumberger JA, Brundage BH, Rader DJ et al. Electron beam computed tomographic coronary calcium scanning: a review and guidelines for use in asymptomatic persons. Mayo Clin Proc 1999; 74: 243-252
• 16 Libby P. Mechanisms of acute coronary syndromes and their implications for therapy. N Engl J Med 2013; 368: 2004-2013
• 17 Thompson PD, Buchner D, Pina IL et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003; 107 (24) 3109-3116
• 18 Nucifora G, Bax JJ, van Werkhoven JM et al. Coronary artery calcium scoring in cardiovascular risk assessment. Cardiovasc Ther 2011; 29: e43-e53
• 19 Karlstedt E, Chelvanathan A, Da Silva M et al. The impact of repeated marathon running on cardiovascular function in the aging population. J Cardiovasc Magn Reson 2012; 14: 58
• 20 Min JK, Dunning A, Lin FY et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23854 patients without known coronary artery disease. J Am Coll Cardiol 2011; 58: 849-860
• 21 Hou ZH, Lu B, Gao Y et al. Prognostic value of coronary CT angiography and calcium score for major adverse cardiac events in outpatients. JACC Cardiovasc Imaging 2012; 5: 990-999
• 22 Hadamitzky M, Achenbach S, Al-Mallah M et al. Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry). J Am Coll Cardiol 2013; 62: 468-476
• 23 Rana JS, Dunning A, Achenbach S et al. Differences in prevalence, extent, severity, and prognosis of coronary artery disease among patients with and without diabetes undergoing coronary computed tomography angiography: results from 10,110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry. Diabetes Care 2012; 35: 1787-1794
• 24 Siscovick DS, Weiss NS, Fletcher RH et al. The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med 1984; 311: 874-877
• 25 Roberts WO, Roberts DM, Lunos S. Marathon related cardiac arrest risk differences in men and women. Br J Sports Med 2013; 47: 168-171
• 26 Ketelsen D, Fenchel M, Thomas C et al. Estimation of radiation exposure of retrospective gated and prospective triggered 128-slice triple-rule-out CT angiography. Acta Radiol 2011; 52: 762-766