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Acute coronary syndrome with ST-segment elevation during exercise testing in a master athlete

Daniel Neunhaeuserer, Sports Cardiology Quiz Section Co-Editor

Preventive Cardiology
Rehabilitation and Sports Cardiology


The case

A 58-year-old male professional marathon runner comes to our sports medicine center for annual pre-participation screening (PPS). He is known for a sensorineural disorder from birth (deaf-mutism) but presented no cardiovascular risk factors other than a mild “white coat” hypertension. He has a sedentary job and a normal diet. All previous PPS visits have been unremarkable.

  • He is 177 cm x 77 kg (BMI of 24.58 kg/m2) with a waist circumference of 85 cm.
  • Resting blood pressure is 135/85 mmHg.
  • Physical examination, urine examination and spirometry show unremarkable findings. 

The 12-lead resting ECG is within normal limits (Figure 1).

Figure 1: ECG at rest

Quiz-2023-Jan-Fig1.JPG

The exercise stress test is performed on the cycle ergometer (following 30 watts x 2 min protocol), with a surgical mask, as recommended by the Italian Sports Medicine Federation (FMSI) recommendations for performing sports medicine examinations during the SARS-CoV-2 pandemic.

At 200 W, 110 bpm (67% of predicted maximum heart rate), a large convex ST-segment elevation suddenly appears between V1 and V6 leads (Figure 2), together with a simultaneous angina sensation of the patient.

Figure 2: ECG at 200 W, 110 bpm: elevation of the ST segment

Quiz-2023-Jan-Fig2.JPG

Test your knowledge

Note: The views and opinions expressed on this page are those of the author and may not be accepted by others. While every attempt is made to keep the information up to date, there is always going to be a lag in updating information. The reader is encouraged to read this in conjunction with appropriate ESC Guidelines. The material on this page is for educational purposes and is not for use as a definitive management strategy in the care of patients. Quiz material on the site are only examples and do not guarantee outcomes from formal examinations.

 

References

1) Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC); Eur Heart J 2018;39:119–77.
2) Hung MJ, Hu P, Hung MY. Coronary artery spasm: review and update. Int J Med Sci 2014;11:1161–71.
3) Matta A, Bouisset F, Lhermusier T, Campelo-Parada F, Elbaz M, Carrié D, et al. Coronary artery spasm: new insights. J Interv Cardiol 2020;2020:5894586.
4) Chahine RA, Raizner AE, Ishimori T. The clinical significance of exercise-induced ST-segment elevation. Circulation 1976;54:209–13.
5) de Feyter PJ, Majid PA, van Eenige MJ, Wardeh R, Wempe FN, Roos JP. Clinical significance of exercise-induced ST segment elevation. Correlative angiographic study in patients with ischaemic heart disease. Br Heart J 1981;46:84–92.
6) Specchia G, de Servi S, Falcone C, Angoli L, Mussini A, Bramucci E, et al. Significance of exercise-induced ST-segment elevation in patients without myocardial infarction. Circulation 1981;63:46–53.
7) Stauber BD, Venugopal S, Amsterdam EA. Treading lightly: ST-segment elevation on an exercise electrocardiogram. Am J Med 2017;130:34–6.
8) Canpolat U, Yorgun H, Aytemir K, Oto A. Precordial ST-segment elevation triggered by treadmill exercise test in a sedentary patient. J Cardiol Cases 2013;8:60–2.
9) John F. Beltrame, Filippo Crea, Juan Carlos Kaski, Hisao Ogawa, Peter Ong, Udo Sechtem, Hiroaki Shimokawa, C. Noel Bairey Merz, On Behalf of the Coronary Vasomotion Disorders International Study Group (COVADIS), International standardization of diagnostic criteria for vasospastic angina, European Heart Journal, Volume 38, Issue 33, 01 September 2017, pages 2565–2568
10) Mapelli M, Salvioni E, De Martino F, Mattavelli I, Gugliandolo P, Vignati C, et al. “You can leave your mask on”: effects on cardiopulmonary parameters of different airway protective mask during maximal exercise. Eur Respir J 2021;58:2004473. 
11) Pasqualetto MC, Tuttolomondo D, Gaibazzi N, Baratella MC, Casolino P, Stefani M, et al. Safety of surgical masks during physical activity evaluated with graded cycle ergometry test. J Sports Med Phys Fitness 2021. [Epub ahead of print] 
12) Nakao K, Ohgushi M, Yoshimura M, Morooka K, Okumura K, Ogawa H, et al. Hyperventilation as a specific test for diagnosis of coronary artery spasm. Am J Cardiol 1997;80:545–9. 

Notes to editor

Author information:

Stefano Palermi 
Public Health Department, University of Naples Federico II, Naples, Italy
Sports and Exercise Clinical Network of Veneto Region, Padova, Italy

Franco Giada 
Unit of Sports Medicine, P.F. Calvi Noale Hospital, Noale, Venice, Italy
Sports and Exercise Clinical Network of Veneto Region, Padova, Italy