IJCS | Volume 32, Nº4, July/August 2019

329 Demand ischemia during endurance exercise is not trivial andwas identified to be the leading cause of cardiac arrest during exercise among aging marathon runners in the Race Associated Cardiac Arrest Registry (RACER). 3 It is also noteworthy that in this study, the highest proportion of these sudden cardiac deaths occurred in the final stretches of themarathonwhen runners typically engage in a “finish-line surge”, suggesting that an intensity-dependent phenomenon may be precipitating malignant ventricular arrhythmia and subsequent cardiac arrest. Overall, these observations suggest that the risk of a “stable CAD” may not be the same in endurance athletes as in their less active counterparts. This may be most pronounced in triathlon participants, described to have a 2-to-3 fold increase in these events. 11 This elevated cardiovascular risk, when coupledwith the general unwillingness of these competitors to take anti- ischemic medications, has the potential to alter the risk/ benefit balance for intervention over medical therapy (or vice versa) for a given FFR or iFR “cut point.” Thus, with stakes this high and indecision regarding the precise role of invasive coronary physiological assessment in competitive athletes, clinicians should be cautious in their interpretation of borderline values. It is within this “grey zone” that measurement uncertainty increases dramatically, 12 and thus acting hastily on one indeterminate data point may be ill-advised. 12 For this reason, functional data fromcarefully conductedmaximal effort, exercise stress test should be obtained before coronary angiography whenever possible and should be considered during the revascularization decision-making process. Among competitive athletes with documented evidence of ischemia during prior functional testing, revascularization of seemingly indeterminate lesionsmay be a preferred option over medical therapy as suggested by a recent European consensus statement (Class IIa). 13 At the present time, ACC/AHA task force guidelines do not provide a definitive recommendation regarding revascularization, but endorse restricting athletes with stable CAD and inducible ischemia to sports with low dynamic and low to moderate static demands (Class IIb). Thus, the decision boils down to restriction from all endurance sports or “elective” revascularization with a goal of eliminating demand ischemia. 14 Despite this difference between European and American recommendations, writing committees fromboth regions identify inducible ischemia as a high-risk feature among competitive endurance athletes. Ultimately, more scientific investigation is needed to identify accurate FFR and iFR cut-points which reflect the true risk/benefit balance of percutaneous revascularization in competitive athletes with CAD. While we await further data, it is prudent to engage the athletic patient in a shared-decision making discussion about medical therapy versus revascularization prior to catheterization as both strategies have distinct pros and cons. This approach enables sports cardiologists and their patients to enter into a clinical decision- making partnership. 15,16 Such sharing of clinical decision making optimally positions the clinician to make revascularization decisions with the patient-athlete, by integrating clinical history, ancillary testing, and individualized goals of care. Author contributions Conception and design of the research: Issa OM, Baggish AL. Acquisition of data: Issa OM, Baggish AL. Writing of the manuscript: Issa OM, Guseh JS, Inglessis I, Baggish AL. Critical revision of the manuscript for intellectual content: Issa OM, Guseh JS, Inglessis I, Baggish AL. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associated with any thesis or dissertation work. Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors. Issa et al. Coronary physiologic in endurance athletes Int J Cardiovasc Sci. 2019;32(4):326-330 Viewpoint