Working Diagnosis:
Multi-vessel CAD, NSTEMI, and paroxysmal atrial fibrillation

Treatment:
He was started on aspirin, Ticagrelor, high dose statin and underwent a left heart catheterization which revealed severe triple vessel disease. Case Photo #4
Multi-vessel coronary artery bypass (CABG) was recommended.
Our patient underwent a successful multi-vessel open heart surgery within 48 hours after admission.

Author's Comments:
Recent studies have shown clear evidence of CAD in athletes. Specifically, we have learned that athletes are not immune to the development of CAD, specifically higher coronary calcification. Evidence suggests that sudden cardiac death in athletes > 35 years of age is related to CAD with fixed obstruction. Our case is yet another example that exercise is not a panacea against the development of CAD, and endurance athletes should be assessed thoroughly for modifiable risk factors. If our athlete had not ignored early exercise induced symptoms, he may have not needed an invasive intervention to save his life.

Editor's Comments:
It is known that adults who exercise have a lower incidence of coronary artery disease, myocardial infarction, and cerebrovascular disease compared to those that do not exercise. CAD can occur, however, in physically fit adults as well as in sedentary adults. Exercising addresses some, but not all, of the "Framingham" risk factors for vascular disease, stroke, and myocardial infarction.
We are taught early in our medical careers that diabetics often do not have typical angina symptoms associated with cardiac events. Adults without diabetes may often present with atypical symptoms. This case is an excellent description of that point.
As a point of care, physicians should emphasize with their fit patients that they should be evaluated for new symptoms. Many conditions, including cardiac, can masquerade as musculoskeletal injuries.

References:
Aengevaeren, V.L., et al., Relationship Between Lifelong Exercise Volume and Coronary Atherosclerosis in Athletes. Circulation, 2017. 136(2): p. 138-148.

Merghani, A., et al., Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile. Circulation, 2017. 136(2): p. 126-137.

Molina, L., et al., Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace, 2008. 10(5): p. 618-23.

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