Chest Pain in a Masters Athlete: Clearing for the Marathon
A 52-year-old man requests preparticipation clearance for his first marathon. He runs 30 miles/week and is asymptomatic at rest and during training. He has hypertension treated with lisinopril, a 20-pack-year smoking history (quit 8 years ago), and a father who had an MI at age 58. He reports one episode of 'heartburn' during a hard tempo run 3 weeks ago that resolved with rest; he did not seek care. Exam: BP 138/86, HR 62, BMI 27, normal cardiac exam, no murmurs, lungs clear. He asks whether he needs 'any tests' before the race.
1. What is his pretest probability of coronary artery disease, and what does the preparticipation evaluation add here?
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He has multiple risk factors: age >50, male, hypertension, former smoker, family history of premature CAD (father MI at 58 - borderline premature by male <55 criteria), and a symptom during exertion ('heartburn' with hard running that resolved with rest). That exertional symptom is the pivotal feature - it converts this from routine screening to symptom evaluation.
Pretest probability of obstructive CAD is intermediate-to-high given age, sex, and symptoms. The preparticipation evaluation's job is not to 'clear' him for a marathon - it is to identify who needs further cardiac evaluation before high-intensity endurance exertion. The PPE should include focused cardiovascular history (syncope, exertional chest pain, dyspnea, palpitations, family history of sudden death), physical exam, and - in a symptomatic athlete - referral, not clearance.
Key point: asymptomatic athletes do not need routine ECG or stress testing for clearance, but a symptomatic athlete with risk factors does. Do not sign the clearance form and move on.
2. What testing do you order, and what are the limitations of exercise stress testing in this athlete?
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Order:
- 12-lead ECG (baseline; also screens for inherited channelopathies/structural clues).
- Exercise stress testing - given he is a runner and can exercise, a maximal treadmill ECG stress test is appropriate and gives functional capacity plus ischemic evaluation.
- Consider echocardiogram if any murmur, abnormal ECG, or symptoms suggest structural disease.
- Coronary CT angiography (CCTA) is a reasonable alternative/adjunct in an intermediate-risk patient, especially if the stress test is equivocal; it has high negative predictive value.
- Standard labs: lipids, glucose/A1c, renal function.
Limitations of stress testing in athletes:
- High functional capacity can mask ischemia - a fit athlete may reach a high workload before symptoms or ECG changes appear, reducing sensitivity in single-vessel disease.
- Baseline ECG changes (LVH, early repolarization, resting bradycardia) common in athletes can reduce specificity and complicate interpretation.
- Exercise ECG has limited sensitivity (~60–70%) for significant CAD; a negative test does not exclude disease, especially in a symptomatic patient.
- Cannot assess plaque burden - a 'normal' stress test in a patient with non-obstructive but high-risk plaque does not guarantee safety during a marathon.
3. He asks: 'If my tests are normal, am I definitely safe to run the marathon?' How do you counsel him, and what is your clearance decision if testing is normal?
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Counsel honestly: no test guarantees safety.
- Normal stress test + normal ECG substantially lowers but does not eliminate risk. Acute plaque rupture - the mechanism of most exercise-related MIs - can occur in non-obstructive disease that stress testing misses.
- Marathon running transiently increases cardiac risk during and immediately after the event, though absolute risk is low and habitual vigorous exercise lowers overall cardiovascular mortality. Frame it as risk modulation, not risk elimination.
- Symptom education: any exertional chest pain, pressure, unusual dyspnea, palpitations, or syncope = stop and seek evaluation. 'Heartburn' during exertion is a red flag until proven otherwise.
- Risk factor optimization: BP control (target <130/80), lipid management per ASCVD risk, no smoking, gradual marathon buildup (avoid abrupt increases in mileage/intensity).
- Event safety: know the course, hydrate, avoid extreme heat, and consider the event's medical plan.
Clearance decision if testing is normal: reasonable to clear with counseling and a plan for symptom-triggered reevaluation, provided his exertional symptom is explained (e.g., GERD) or resolved and BP is controlled. If the exertional symptom remains unexplained or testing is equivocal/abnormal, defer clearance and pursue further evaluation (cardiology referral, CCTA). The decision is shared, documented, and conditional - not a blanket 'you're fine.'