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Risk and Treatment Decisions for Primary Prevention in the Athlete: Worth Going the Extra Mile

      High-volume master endurance athletes present unique challenges for the clinician tasked with risk stratification and, if needed, therapy initiation for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). Although recent 2018 and 2019 prevention guidelines emphasize heart-healthy lifestyle—including physical activity for all patients—cardiorespiratory fitness (CRF) is not used in ASCVD risk estimation for adults aged between 40 and 75 years.
      • Grundy SM
      • Stone NJ
      • Bailey AL
      • Beam C
      • Birtcher KK
      • Blumenthal RS
      • Braun LT
      • de Ferranti S
      • Faiella-Tommasino J
      • Forman DE.
      2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
      However, several studies have demonstrated that low CRF is a stronger predictor of risk for adverse cardiovascular outcomes than are traditional risk factors, including lipid abnormalities, hypertension, insulin resistance, obesity, and smoking.
      • Ross R
      • Blair SN
      • Arena R
      • Church TS
      • Després JP
      • Franklin BA
      • Haskell WL
      • Kaminsky LA
      • Levine BD
      • Lavie CJ
      • Myers J
      • Niebauer J
      • Sallis R
      • Sawada SS
      • Sui X
      • Wisløff U
      American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health, Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, Stroke Council. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.
      Conversely, multiple studies have demonstrated the benefit of high CRF, with CRF levels >8 to 10 METs associated with relative protection from cardiovascular events and mortality.
      • Ross R
      • Blair SN
      • Arena R
      • Church TS
      • Després JP
      • Franklin BA
      • Haskell WL
      • Kaminsky LA
      • Levine BD
      • Lavie CJ
      • Myers J
      • Niebauer J
      • Sallis R
      • Sawada SS
      • Sui X
      • Wisløff U
      American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health, Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, Stroke Council. Importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the American Heart Association.
      Studies have estimated an up to 12% increase in overall survival in men for every increase in one MET in exercise capacity.
      • Myers J
      • Prakash M
      • Froelicher V
      • Do D
      • Partington S
      • Atwood JE.
      Exercise capacity and mortality among men referred for exercise testing.
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