Asymptomatic ST-segment changes in athletes with myocardial bridge: unremarkable or dangerous?

Coronary artery anomalies are a cause of sudden death in athletes in the absence of additional heart abnormalities.Understanding the pathophysiology is important in guiding management because variations in coronary anatomy are common.Myocardial bridging (intramural coronary artery) is a common congenital coronary anomaly that involves almost exclusively the left anterior descending coronary artery (LAD), and is regarded as a common anatomic variant rather than a congenital anomaly.It is clinically silent in the majority of cases.Asymptomatic athletes with positive exercise testing have a high probability of having a myocardial bridge.So the presence of ventricular repolarization abnormalities, such as ST segment depression, during stress tests meet clear indication to investigate by means of coronary computed tomography to rule out the presence of this anomaly.Here the authors describe a case of a middle-aged competitive athlete who presented a positive exercise test and was withdrawn from competition for the coexistence of a deep and long myocardial bridge at high risk of sudden death.