p.23 抽出テキスト
................................................................................................................................. incidence of adverse outcomes from CAD, but prolonged, highintensity endurance exercise has been associated with increased coronary artery calcium (CAC), a marker of atherosclerosis,58,222 and coronary plaques58 but without an increase in mortality112 in the medium term. Importantly, the diagnosis of myocardial injury is also more complex in athletes because intense exercise may increase serologic markers of myocardial injury, including cardiac troponin I and T.223,224 5.1.1 Individuals at risk of atherosclerotic coronary artery disease and asymptomatic individuals in whom coronary artery disease is detected at screening Athletes or individuals participating in sports or regular exercise training may have risk factors for CAD and/or subclinical CCS.225 Such individuals may be identified by routine pre-participation screening as recommended by the ESC21 or by pre-evaluation of master athletes, as suggested by the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) 2011207 and the AHA.226 In addition to the SCORE risk stratification described earlier (Table 5), the increasing use of cardiac imaging techniques allows the identification of a greater number of individuals with asymptomatic CCS,227 including competitive master athletes.227 Newer predictive measures, such as high-sensitive C-reactive protein and carotid intimamedia thickness (IMT) add little to the traditional risk factors.110 The exception is CAC, which provides additional predictive information in individuals with a moderate-risk profile,228 dividing them into low- or high-risk individuals. The most prudent and cost-effective method of utilizing CAC may thus be additive to the traditional risk factors,229 as suggested by the EAPC.230 Clinical evaluation of asymptomatic individuals with possible subclinical CCS should include (Figure 4):112 (1) Assessment of risk of CVD110 (Table 5) (2) Consideration of intensity of intended exercise programme (3) Clinical evaluation, including maximal exercise stress test (4) Further diagnostic testing in selected individuals. Many middle-aged individuals in the general population can be expected to have some level of subclinical CCS as assessed with imaging techniques. Anatomical coronary imaging alone does not provide information relating to the coronary flow and reserve, which is important in assessing the risk of Ex-R ischaemia or SCD/SCA; therefore functional evaluation is necessary. Several methods of stress testing (e.g. cycle ergometry or treadmill testing), stress echocardiography, adenosine or dobutamine stress cardiac magnetic resonance (CMR), or positron emission tomography (PET)/single-photon emission computed tomography (SPECT), can be used to detect inducible myocardial ischaemia231. Exercise stress-echo is preferred in athletes because it is free from radiation and does not involve administration of drugs. Exercise testing is the most widely available functional test, and provides information on exercise capacity, heart rate, and BP response, and detection of exercise-induced arrhythmias,2 but has a lower specificity for myocardial ischaemia than other functional tests, especially in asymptomatic and low-risk individuals. It is recommended that a truly maximal exercise test232 (with or without CPET) should be performed when evaluating individuals with possible subclinical (or clinical) CCS who intend to or are participating in systematic exercise including recreational or competitive sports. Whether the initial exercise test includes imaging or not depends on factors such as the baseline ECG (Table 9) and feasibility of performing functional imaging tests in a given institute. • If the clinical assessment, including a maximal exercise test is normal, the presence of ‘relevant CAD’ is assumed to be unlikely (Figure 4). • In the event of a borderline or uninterpretable exercise test result, it is recommended that a more specific imaging stress test is performed such as stress-echocardiography, CMR perfusion imaging, or SPECT. Maximal exercise SPECT and exercise echocardiography or nuclear perfusion techniques utilizing exercise rather than pharmacological stress may preferentially be used, depending on availability and local expertise. • If the exercise test is positive, an invasive coronary angiogram should be performed to confirm the presence, extent, and severity of CAD (Figure 4). 5.1.1.1 Recommendations for sports participation Individuals at risk of CAD and asymptomatic individuals in whom CAD is detected at screening should have aggressive management of risk factors for atherosclerosis.6,131,132,202 Considering the benefits of exercise on primary and secondary prevention of CCS,6,234 individuals with risk factors should be restricted from competitive sport only when there is substantial risk of an adverse event, as indicated by functional tests, or when there is evidence of disease progression during serial evaluations.233 Exercise recommendations should be individually tailored based on the intensity of the exercise and the sporting discipline. Participation in competitive endurance, power, and mixed disciplines (see sections 4.2 and 5.1.3) generally requires vigorous effort and is more likely to induce myocardial ischaemia, whereas leisure sports or intentional recreational exercise allows for greater control of physical effort. Individuals with a high risk of atherosclerotic CAD and asymptomatic individuals in whom CAD is detected at screening who participate in intensive exercise should be assessed with a maximal exercise test or functional imaging test on an annual basis. Table 9 Borderline or uninterpretable ECG findings ©ESC 2020 Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026