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Aspirin to Prevent Sudden Cardiac Death in Athletes with High Coronary Artery Calcium Scores

Pheidippides’ sudden cardiac death in the Atheneum in 490 B.C. after declaring victory over the invading Persian army on the Plains of Marathon (by anonymous).
Unforseeing one! Yes, he fought on Marathon day: So, when Persia was dust, all cried “To Akropolis! Run, Pheidippides, one race more. Till in Athens he broke, ‘Rejoice, we conquer!” Joy in his blood bursting his heart, he died—the bliss! ‘Pheidippides’ by Robert Browning, 1879.

While proficient cardiac resuscitation has improved survival following cardiac arrest during road races in Japan, this accomplishment does not address coronary artery disease as the underlying cause of an increasing frequency of cardiac arrest in middle-aged men during marathons and ironman triathlons in the United States since the year 2000. Based on the high prevalence of subclinical coronary artery disease by cardiac computed tomography in endurance athletes with low conventional cardiac risk-factor profiles, we recommend coronary artery calcium scores as a more reliable and independent predictor of incident cardiac events, including death, as validated among adults aged 30-46 years. Scores of over 100 Agatston units indicate a 10-year cardiac risk of 7.5%, at which additional measures for primary prevention are recommended, including aspirin, as shown conclusively to reduce first myocardial infarctions in same-aged men in a prospective double-blind controlled trial. Targeted screening for subclinical coronary atherosclerosis with coronary artery calcium scores is prudent to guide appropriately dosed aspirin use to mitigate the increasing frequency of sports-related sudden cardiac death due to plaque rupture.

While the incremental cardioprotective benefit of increasing sports participation is indisputable, vigorous exercise may also trigger sudden cardiac death.1 A reduction in fatalities by proficient cardiac resuscitation in road races in Japan warrants timely replication worldwide, as prospective registries in the United States and Europe document a similar high incidence of cardiac arrest (1 per 65,509 or 1.53 per 100,000) during road races, mainly in men with an average age under 50 years.2, 3, 4 Their accomplishment does not, however, address coronary artery disease as the root cause of an excess of premature cardiovascular morbidity and mortality during marathons and ironman triathlons in the United States since the year 2000.3, 4, 5, 6

Based on male sex and the marathon as significant risk factors for cardiac arrest in US races since 2000, a single dose of prerace aspirin has been recommended to mitigate the transient high cardiac risk for participants in marathons and triathlons whose 10-year cardiovascular risk usually falls below the threshold, indicating a net benefit for continuous prophylaxis by conventional measures.7, 8, 9, 10 An increased incidence of acute cardiovascular events after discontinuing aspirin for primary prevention is the latest evidence to support this recommendation, which corroborates the conclusive (44%) decrease in first acute myocardial infarctions in middle-aged men in the Physicians Health Study, a randomized controlled primary prevention trial.11, 12

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-Arthur J. Siegel, MD, Timothy D. Noakes, MD

This article originally appeared in the February issue of The American Journal of Medicine.

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