Your athlete-patient has a high coronary artery calcification score—‘Heart of Stone’. What should you advise? Is exercise safe?

Coronary artery calcification (CAC) is a strong marker of subclinical coronary atherosclerosis and leading authorities recommend CAC scoring to help inform patient management decisions in cardiovascular disease (CVD) prevention.1 2 This will result in an increasing number of athlete-patients with subclinical coronary atherosclerosis presenting to sport and exercise medicine physicians, raising questions about exercise recommendations in this subgroup. With a specific focus on the recent outcomes data of DeFina and colleagues3 we extend our recent discussion of the topic2 by focusing on how to manage athlete-patients with elevated CAC in the sport and exercise medicine setting. A breakthrough in reporting the association of CAC and mortality risk across different activity levels came from a recent study of 21 758 healthy male participants without prevalent CVD. Higher levels of leisure-time physical activity were associated with a lower risk of mortality at any given level of CAC.3 The authors reported a higher risk metabolic profile (ie, higher baseline blood pressure, higher glucose concentrations and higher triglycerides) in the high volume exercise group with elevated CAC ≥100 AU …