CORRESPONDENCE: LETTER TO THE EDITOR
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Domenico Corrado, MD, PhD*,
Cristina Basso, MD, PhD,
Maurizio Schiavon, MD,
Antonio Pelliccia, MD and
Gaetano Thiene, MD
* Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Via Giustiniani, 2, Padua 35121, Italy (Email: domenico.corrado{at}unipd.it).
We thank Dr. Reich for his interest in our review (1). We agree with his comments that congenital coronary artery anomaly is an important cause of sudden death in young competitive athletes and that its clinical detection in young competitive athletes undergoing pre-participation screening is challenging. The most frequent anatomical variant leading to cardiac arrest consists of both coronary arteries arising either from the right or the left coronary sinus, with the aberrant coronary artery coursing between the aorta and the pulmonary trunk. Retrospective analyses of clinical and pathological series have consistently shown that neither routine 12-lead electrocardiogram (ECG) nor exercise testing are particularly informative for the diagnosis of the anomalous origin of a coronary artery from the wrong coronary sinus (2). False-negative results of exercise testing in subjects who have subsequently died suddenly from coronary anomalies have been explained by the difficulty of reproducing in the clinical setting the peculiar mechanisms of myocardial ischemia because of the aberrant coronary artery origin and course. Hence, a negative ECG at pre-participation screening does not exclude a potentially lethal coronary anomaly. Although sudden death may be the first manifestation in patients with wrong sinus coronary artery origin, premonitory symptoms such as syncope or chest pain occur in a substantial proportion of affected individuals, predominantly during physical exercise. This emphasizes the need to raise the index of clinical suspicion in young competitive athletes complaining of effort-related relevant cardiac symptoms. We agree with Dr. Reich that systematic echocardiographic examination of the origin and course of coronary arteries is expensive and unfeasible for screening large athletic populations because of its prohibitive costs and limited diagnostic accuracy. A viable strategy for clinical identification of coronary artery anomalies at pre-participation screening, based on ECG but also on personal history and physical examination, is the selected evaluation of symptomatic athletes (2). The origin of coronary arteries should be assessed noninvasively by echocardiography when the index of suspicion is sufficiently high because of the presence of exertional syncope or chest pain (even in the absence of ECG abnormalities). In this regard, Pelliccia et al. (3) showed that echocardiographic imaging of the proximal tract of the left and right coronary arteries is feasible and reliable in a substantial proportion of young athletes (about 95%). Failure to show that coronary arteries actually originate from their usual coronary sinuses in a young symptomatic athlete should prompt further characterization of the coronary artery anatomy by either conventional coronary angiography or modern imaging techniques such as coronary artery computed tomography or cardiac magnetic resonance.
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1. Corrado D, Basso C, Schiavon M, Pelliccia A, Thiene G. Pre-participation screening of young competitive athletes for prevention of sudden cardiac death J Am Coll Cardiol 2008;52:1981-1989.[Abstract/Free Full Text]2. Basso C, Maron BJ, Corrado D, Thiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes J Am Coll Cardiol 2000;35:1493-1501.[Abstract/Free Full Text] 3. Pelliccia A, Spataro A, Maron BJ. Prospective echocardiographic screening for coronary artery anomalies in 1,360 elite competitive athletes Am J Cardiol 1993;72:978-979.[CrossRef][Web of Science][Medline]
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