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In the middle of the journey of his life - the straight way was lost*

Daniel Neunhaeuserer, Sports Cardiology Quiz Section Co-Editor

*based on a quote from Dante Alighieri

A 40-year-old male, asymptomatic, amateur runner performing preparticipation screening with maximal exercise testing.

Preventive Cardiology
Rehabilitation and Sports Cardiology

The case

The patient in this clinical case – like Dante Alighieri, the famous Italian poet – had to face certain troubles in the middle of the journey of his life. A 40-year-old male, Caucasian, amateur runner, approached our institute for a preparticipation screening for competitive sports activities. Asymptomatic at rest and during exercise. He had no family history for sudden cardiac death or heart diseases. He reported only hypercholesterolaemia (TC: 220 mg/dL) in familial dyslipidaemia and mild mitral valve prolapse, in regular echocardiographic follow-up. 

Clinical examination was normal, resting arterial blood pressure in optimal control (105/65 mmHg).

Resting ECG was normal for athletes, showing sinus rhythm, 59 bpm and an incomplete right bundle branch block (Figure1). 

Figure 1: resting ECG


The patient was at low risk according to the SCORE2 cardiovascular risk chart (SCORE2 < 2.5%)

He performed a maximal exercise test on a treadmill, RPE 18/20 reaching 90% of age-related maximum heart rate. Figures 2 and 3 show the athlete’s 12-lead ECG at peak exercise and at the second minute of recovery, respectively. The patient was always asymptomatic during exercise and in the recovery period; no major arrhythmias have been registered.

Figure 2: ECG at peak exercise 


Figure 3: ECG at the second minute of recovery


How would you describe these findings in your medical report, and would you prescribe further second-line investigations, based on which clinical suspicion?

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.


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3.    Guazzi M, Adams V et Al. European Association for Cardiovascular Prevention & Rehabilitation; American Heart Association. EACPR/AHA Scientific Statement. Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation. 2012;126(18):2261-74. 
4.    Belardinelli R, Lacalaprice F et Al. Cardiopulmonary exercise testing is more accurate than ECG-stress testing in diagnosing myocardial ischemia in subjects with chest pain. Int J Cardiol. 2014;174(2):337-42.
5.    Ermolao A, Roman F et Al,  Coronary CT angiography in asymptomatic middle-aged athletes with ST segment anomalies during maximal exercise test. Scand J Med Sci Sports. 2016;26: 57–63. 
6.    Finocchiaro G, Behr ER et Al. Anomalous Coronary Artery Origin and Sudden Cardiac Death. Clinical and Pathological Insights from a National Pathology Registry. J Am Coll Cardiol EP. 2019;5:516–22.
7.    Gentile F, Castiglione V et Al. Coronary Artery Anomalies. Circulation. 2021;144(12):983-996.
8.    Pelliccia A, Sharma S et Al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2020;1-80.

Notes to editor

Author information:

Borasio, Nicola, MD
Quinto, Giulia, MD
Favero, Claudia, MD
Ermolao, Andrea, MD
Neunhaeuserer, Daniel, MD, PhD

Sports and Exercise Medicine Division, Department of Medicine, University of Padova.

Sports and Exercise Medicine Clinical Network of Veneto Region, Italy.