IJCS | Volume 32, Nº4, July/August 2019

DOI: 10.5935/2359-4802.20190063 Abstract Despite the health benefits of routine exercise, coronary artery disease (CAD) is common among older competitive athletes and is an important cause of sudden cardiac death. Athletes with suspected or confirmedCAD routinely undergo conventional coronary angiography involving the performance of invasive coronary physiological assessment using the fractional flow reserve (FFR) or the instantaneous-wave free ratio (iFR). Data defining the role of invasive coronary physiological assessment, while robust in general clinical populations, are untested among older competitive athletes with CAD. The paper discusses the challenges and uncertainties surrounding the use of the FFR and iFR in this unique populationwith an emphasis on the need for future work to better define this approach. Introduction Although routine vigorous exercise promotes favorable changes in atherosclerotic vascular risk factors, it cannot provide complete immunity fromcoronary artery disease (CAD), regardless of its level. CAD is common among older competitive athletes, 1 and is an important cause of sudden cardiac death. 2,3 Effective clinical management of athletes with CAD, much like non-athletic patients, requires a strategy that integrates lifestyle modification, pharmacotherapy, and coronary revascularization. Most athletes with CAD, with diagnosis made by symptoms, abnormal findings during functional testing, or through the increasing use of computed tomography screening will undergo conventional coronary angiography. This method facilitates a definitive determination of coronary anatomy and provides an opportunity for simultaneous percutaneous revascularization. The decision to perform percutaneous coronary revascularization in competitive athletes depends on medical therapy options and coronary lesion severity. For determination of coronary lesion severity, visual inspection of coronary anatomy has been increasingly associated with invasive coronary physiology analysis, which has emerged as a powerful tool to guide coronary revascularization decisions. Measurement of the fractional flow reserve (FFR), and more recently, the instantaneous-wave free ratio (iFR) to assess the functional significance of angiographically intermediate coronary stenoses have been shown to improve clinical outcomes, 4–7 and has been established as the standard of care for the general population. 8 However, competitive athletes represent a population with unique physiology where these modalities have not been well validated. Thus, application of data derived from non-athletic populations has the potential to lead clinicians astray. This paper examines¬ the use of invasive coronary physiological assessment among athletes with coronary disease, with an emphasis on potential limitations that arise from the absence of physiologic and outcome data derived from this specific population. Aaron L. Baggish MD, F.A.C.C., F.A.C.S.M. Associate Professor of Medicine, Harvard Medical School Director, Cardiovascular Performance Program Massachusetts General Hospital abaggish@partners.org 326 VIEWPOINT International Journal of Cardiovascular Sciences. 2019;32(4):326-330 Mailing Address: Aaron L. Baggish Cardiovascular Performance Program Massachusetts General Hospital. 55 Fruit St, Yawkey Suite 5B, Boston, MA 02114 - EUA E-mail: abaggish@partners.org Invasive Coronary Physiological Assessment in Symptomatic Middle-Aged Endurance Athletes Omar M. Issa , J . Sawalla Guse h, Ignacio Inglessi s, A aron L. Baggis h Massachusetts General Hospital, Boston, MA - EUA Manuscript received on April 12, 2019; reviewed on May 01, 2019; accepted on May 04,2019. Athletes; Adult; Circuit Based Exercise/mortality; Physical Fitness; CoronaryArteryDisease; Fractional Flow Reserve; Myocardial; Coronary Angiography/methods. Keywords