Silent Myocardial Ischemia in Master Marathon Runner

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the
absence of angina or anginal equivalents. Silent myocardial ischemia is quite different from silent
coronary artery disease. The symptomatic angina is the tip of the ischemic iceberg and it is less
frequent in athletes than in non-athletes. Athletes change their perception of ischemic stimulus and
increasing pain threshold from increased circulating endorphin levels. Silent myocardial ischemia is
more prevalent than angina in patients with coronary artery disease, and athletes are not immune to
it. In order to discover early stages of malignant neoplasia (e.g. breast and colon cancer) in the
asymptomatic stage and thus prevent reaching final stages of the disease, screening
participation has been widely accepted. Vice versa, although atherosclerotic cardiovascular disease
causes more deaths and disabilities than all causes of death correlated to cancer, there are
no precise guidelines concerning the screening of asymptomatic elements suffering from
atherosclerosis. There are a number of reports of exercise-related sudden deaths and myocardial
infarctions in aerobically trained athletes suffering from exercise - induced silent myocardial ischemia.
The most appropriate and common method to discover silent myocardial ischemia is exercise stress
testing. Therefore, in this chapter the authors describe three emblematic cases of silent myocardial
ischemia detected in master marathon runners during systematic pre-participation screening. These
marathon runners were asymptomatic but were suffering from a severe coronary artery disease that
was detected only thanks to exercise treadmill stress test, and were then properly treated. Silent
myocardial ischemia is not such a rare event in athletes, indeed quite the opposite. In fact, even
though athletes are asymptomatic this does not exclude the possibility that they are suffering from
severe coronary artery disease.