Assessment and management of atherosclerosis in the athletic patient

Many patients and physicians correctly associate physical activity with reduced cardiovascular morbidity and mortality. Vigorous physical exertion is paradoxically associated with a transient increase in the risk of cardiovascular events and sudden cardiac death. This review extrapolates data from the general population to the management of athletes with symptoms suspicious for coronary artery disease or with prior cardiac events. A history to elicit an athlete's concerns and symptoms combined with a physical examination should guide the decision for preparticipation exercise testing for athletes without prior cardiac events. Athletes with established coronary artery disease should receive aggressive secondary prevention regimens, with special attention to adverse effects that may be unique to this group. There may be benefit in taking time away from competitive athletics to allow for stabilization of coronary artery disease with cholesterol-lowering therapy and, therefore, reduction of future risk. Exercise testing is important for defining risk before the return to participation for athletes who have sustained a cardiac event. Many athletes will ultimately be able to return to full participation provided they have received aggressive therapy and understand the residual risk associated with vigorous physical exertion in the setting of coronary artery disease.