Working Diagnosis:
Acute coronary syndrome due to demand ischemia from secondary iron deficiency anemia

Treatment:
She was transfused two units of packed red blood cells and discharged in stable condition with instructions to take ferrous sulfate 325mg twice daily and 1000 international units of Vitamin C daily.

Outcome:
After discharge, the athlete was evaluated in cardiology clinic 1 week after discharge where a follow-up stress echocardiogram and high sensitivity troponin were performed and found to be normal. The athlete successfully returned to practice one week later with a step-wise conditioning program. Three weeks later she was symptom free and successfully returned to competition.
Her hemoglobin was checked 3-months later with improvement to 11.

Author's Comments:
This case demonstrates a unique presentation of how an underlying chronic history of anemia can lead to cardiac demand ischemia in a highly conditioned athlete. In the initial workup, it is imperative to rule out cardiac structural and conduction abnormalities. When evaluating anemia, one should consider the various etiologies such as blood loss, gastrointestinal malabsorption, nutritional deficiency, auto-immune, hereditary, infectious, and metabolic causes. When treating iron deficiency anemia in adults, the standard dose of elemental iron is 120mg per day for a minimal duration of 3 months. Ferrous sulfate 325mg tablets contains 65mg of elemental iron.

Editor's Comments:
The incidence of iron deficiency anemia in female collegiate athletes is estimated at 5% depending on sport and iron deficiency without anemia much higher at 25-30%. Negative iron balance can lead to iron deficiency and eventually iron deficiency anemia (IDA). Symptom screening and consideration for laboratory evaluation should be a part of the pre-participation evaluation. This athlete had significant anemia that led to fatigue, exertional dyspnea, and ultimately cardiac symptoms while her labs and ECG were consistent with myocardial ischemia. In the general population, anemia is present in one third of the patients diagnosed with acute coronary syndrome but this is generally in an older population. A hemoglobin less than 10 g/dL increases the odds of cardiovascular death at 30 days by 2.5 fold (OR 2.50, CI 1.42-4.39) in the general population. While anemia can result in ischemia related to lower oxygen carrying capacity to the myocardium, an anomalous coronary artery could also affect the ability of the anemic blood to get to the myocardium. Cardiac CT can be used to elucidate the presence and morphology of anomalous coronary arteries while a stress MRI can non-invasively evaluate the functional impact of anomalous coronary arteries on myocardial perfusion.

References:
Parks RB, Hetzel SJ, Brooks MA. Iron Deficiency and Anemia among Collegiate Athletes: A retrospective Chart Review. MSSE. 2017 Aug;49(8):1711-1715.

Kaiafa G, Kanellos I, Savopoulos C, et al. Is Anemia a new cardiovascular risk factor? Int J Cardiol. 2015;186:117-24.

Noel C. Cardiac Stress MRI evaluation of anomalous aortic origin of a coronary artery. Congen Heart Dis. 2017 Sep;12(5): 627-629.

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