Aaron Baggish, MD University of Lausanne

1. The Misunderstood Role of Coronary Calcium Scoring
in Determining Cardiovascular Risk in
Aerobic Endurance Athletes
Aaron Baggish MD
Professor of Medicine, Institut des sciences du sport (ISSUL)
Centre hospitalier universitaire Vaudois (CHUV)
University of Lausanne, Switzerland
Emeritus Director, Cardiovascular Performance Program
Harvard Medical School, Boston, MA, USA
Aaronleigh.baggish@unil.ch

2. Financial Disclosures
Affiliations:
Funding Sources:
– National Institutes of Health
– American Heart Association
– American Society of Echocardiography
– Department of Defense
– National Football League Player’s Association
– American Medical Society for Sports Medicine

3. Why we always knew…
JAMA
1985
NEJM
2002
JAMA
2003
Circulation
2007

4. What we once thought…..

5. What we now know…..

6. Why do athletes get CAD?

7. Why do athletes get CAD?
✓
✓
✓
✓
✓ ✓
✓

8. What do we know about CAC?
Powerfully Prognostic in General Population:
Framingham, MESA, Heinz Nixdorf, etc.
Coronary calcification is a
non-specific marker of
coronary injury &
subsequent repair
Coronary calcification is
not the problem but
rather a surrogate marker
of clinically relevant
disease

9. Be careful with general
population extrapolations?
The Historic Paradigm: Cardiomegaly
Arch Int Med 1958;122:340

10. Plaque Prevalence
42(A) vs. 22(C) %
What do we know about CAC?

11. What do we know about CAC?
Sedentary CAC  Athletic CAC
Mechanistic Evolution of CAC in Athletes?
↑ Fitness ↑ Longevity
↑ CAC
Prognostic Significance of CAC in Athletes?
Traditional CRF
Therapeutic Implications of CAC in Athletes?
↑ CAC
vs.
Given these uncertainties, I do not recommend routine
use of calcium scoring in athletic patients

12. Greater Curvature
Salt n’ Pepper
Calcification
6-8 mm
“The diameter of the coronary
arteries was two to three times
normal, and there was only
minimal calcific
atherosclerosis”
Complex
Atherosclerotic
Plaque
2mm
“There was severe complex
multi-vessel coronary
atherosclerosis with diffuse
lipid deposition and a
preponderance of calcific and
fibrotic organization”
What do we know about CAC?
Mechanical Stress
Proximal Coronary
Isolated / Dense CAC
Risk-Factor Mediated
Diffuse Process
CAC + Lipids/ Inflam.
The Athlete CAC Spectrum
Benign
Phenotype
Lethal
Phenotype
CAC Score ~ 1000 CAC Score ~ 1000

13. What do we know about CAC?
For these reasons, I almost NEVER order a CAC CT in aging athletes…
With one exception….a picture is worth 1000 words
But, we all have to be ready to assess the athlete
who comes to clinic with a CAC score in hand

14. Assessment of Athletes with CAC
Elevated / Detectable CAC
Take a Detailed Physical Activity History
Determine Why the CT was Ordered
(Symptoms, Prognosis, Risk Factor Rx)
Maximal Effort Exercise Test
Define & Treat “Risk Factors”
(HTN, HLP, Tobacco, Glucose, Diet, Family Hx)
Completely Asx,
Preserved
Performance
Reassure, Educate,
Never Order Another CT
(-) Ischemia
+
Symptoms or
Performance
Decline
Angiography (Invasive vs. CT)
(+) Ischemia+/OR
Individualized Revascularization +/- Med Mgmt

15. SCD Prevention: Athletes with CAD
What you don’t measure (and can’t control for) is as important
than what you do measure (and control for)….

16. SCD Prevention: Athletes with CAD
Recognize that no amount of
fitness or physical activity confers
immunity from CAD
NOTHING is 100% Effective
Emergency Action Planning
Assess & Manage Risk Factors
(R.F.) both Traditional and Novel
Utilize maximal effort functional
testing often and early among
those with risk
Tailor Revascularization &
Medical Therapy Based on
Patient Preferences
Individually Define Exercise &
Competition Strategies (SDM)
Traditional R.F.
Age
Current/Past Tobacco Use
Glucose Intolerance
Hypertension
Hyperlipidemia
Non-Traditional R.F.
Habitual Physical Activity
Dietary Choices
Family ASCVD Profile
Work / Family Life
P.E.D. Use
+

17. SCD Prevention: Athletes with CAD
+ +
We will never be perfect, so let’s be ready!
Physician Leaders in the Community Have a Responsibility and an Opportunity

18. THANK YOU