Transcatheter valve repair of tricuspid regurgitation with the PASCAL system: TriCLASP study 30-day results.

BACKGROUND: Severe tricuspid regurgitation (TR) is independently associated with increased morbidity and mortality. Percutaneous transcatheter approaches may offer an alternative for patients not amenable to surgery. METHODS: TriCLASP is a prospective, single-arm, multicenter European post-market clinical follow-up study (NCT04614402) to evaluate the safety and performance of the PASCAL system (Edwards Lifesciences) in patients with severe or greater TR. At 30 days, a composite of major adverse events (MAEs) adjudicated by a clinical events committee, echocardiographic parameters adjudicated by core laboratory, and clinical, functional, and quality-of-life measures were evaluated. RESULTS: Mean age of the 74 enrolled patients was 80.3 years, with 58.1% female, 90.5% systemic hypertension, and 77.0% in New York Heart Association (NYHA) class III/IV. Mean Society for Thoracic Surgeons score (MV repair) was 9.0%. TR severity was significantly reduced at discharge (p < 0.001) and sustained at 30 days (p < 0.001), and 90.0% of patients achieved ≤moderate TR. The composite MAE rate at 30 days was 3.0%, including 4 events in 2 patients: cardiovascular mortality 1.5%, stroke 1.5%, renal complications requiring unplanned dialysis or renal replacement therapy 1.5%, and severe bleeding 1.5%. There were no nonelective tricuspid valve reinterventions, major access site and vascular complications, major cardiac structural complications, or device embolizations. NYHA class I/II was achieved in 55.8%, 6-minute walk distance improved by 38.2 m (p < 0.001), and Kansas City cardiomyopathy questionnaire scores improved by 13.4 points (p < 0.001). CONCLUSION: Experience with the PASCAL transcatheter valve repair system in a European post-market setting confirms favorable safety and effectiveness at 30 days. TR significantly reduced, and clinical, functional, and quality-of-life outcomes significantly improved. This study is ongoing. Clinical Trial Registration: The study is ongoing and registered on ClinicalTrials.gov as NCT04614402. The current analysis is an interim report.

Income-Related Peripheral Artery Disease Treatment: A Nation-Wide Analysis from 2009-2018.

Economic status has a measurable and significant effect on cardiovascular health. Socioeconomic- and income-related disparities worsen cardiovascular risk factors. Peripheral artery disease (PAD) remains a major risk factor for morbidity and mortality. Not all patients benefit equally from recent advances in outpatient healthcare. The implementation of guideline recommendations regarding treatment is inadequate. Income-related disparities for PAD treatment are unknown. We aimed to analyse income-stratified PAD prevalence, outpatient treatment and pharmacotherapy. Associations of statutory health insurance physicians at the regional level, income-stratified PAD prevalence and differences in outpatient care and pharmacotherapy were analysed in 70.1 million statutorily insured patients/year between 2009 and 2018. Analysis was based on claims data (§295 of the social code (SGB V)) and drug-prescription data (§300 SGB V). The diagnosis of PAD was defined by ICD I70.2-9. Regional income data were derived from the German Census Bureau. PAD prevalence was higher in low-income than in high-income areas. Low-income patients more often presented to angiology outpatient care and more frequently received guideline recommended pharmacotherapy. High-income patients more often presented to outpatient vascular surgery. This was true for statins, antiplatelets, intermittent claudication and critical limb ischemia alike. These data indicate that PAD and income are associated. Regional income is related to insufficiencies in guideline-recommended treatment and contact to vascular specialists. Our results aim to encourage medical professionals to implement PAD guideline recommendations, especially in high-income areas. Further studies on associations between spatial-level income and healthcare in PAD are needed.

Socioeconomic position is associated with N-terminal pro-brain natriuretic peptide (NT-proBNP)-Results of the population-based Heinz Nixdorf Recall study.

OBJECTIVES: N-Terminal pro Brain Natriuretic Peptide (NT-proBNP) is a diagnostic marker for heart failure and a prognostic factor for cardiovascular disease (CVD). The aim of this study was to examine the association of socioeconomic position (SEP) with NT-proBNP while assessing sex-differences and the impact of CVD risk factors and prevalent CVD on the association. METHODS: Baseline data of 4598 participants aged 45-75 years of the Heinz Nixdorf Recall Study were used. Income and education were used as SEP indicators. Age- and sex-adjusted linear regression models were fitted to calculate effect size estimates and 95% confidence intervals (95%-CIs) for the total effect of SEP indicators on NT-proBNP, while potential mediation was assessed by additionally accounting for traditional CVD risk factors (i.e., systolic blood pressure, HDL cholesterol, LDL cholesterol, diabetes, anti-hypertensive medication, lipid-lowering medication, BMI, current smoking). Education and income were included separately in the models. RESULTS: With an age- and sex-adjusted average change in NT-proBNP of -6.47% (95%-CI: -9.91; -2.91) per 1000€, the association between income and NT-proBNP was more pronounced compared to using education as a SEP indicator (-0.80% [95%-CI: -1.92; 0.32] per year of education). Sex-stratified results indicated stronger associations in men (-8.43% [95%-CI: -13.21; -3.38] per 1000€; -1.63% [95%-CI: -3.23; -0.001] per year of education) compared to women (-5.10% [95%-CI: -9.82; -0.01] per 1000€; -1.04% [95%-CI: -2.59; 0.50] per year of education). After adjusting for CVD risk factors some of the observed effect size estimates were attenuated, while the overall association between SEP indicators and NT-proBNP was still indicated. The exclusion of participants with prevalent coronary heart disease or stroke did not lead to a substantial change in the observed associations. CONCLUSIONS: In the present study associations of education and income with NT-proBNP were observed in a population-based study sample. Only parts of the association were explained by traditional CVD risk factors, while there were substantial sex-differences in the strength of the observed association. Overt coronary heart disease or stroke did not seem to trigger the associations.

Extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock - Design and rationale of the ECLS-SHOCK trial.

BACKGROUND: In acute myocardial infarction complicated by cardiogenic shock the use of mechanical circulatory support devices remains controversial and data from randomized clinical trials are very limited. Extracorporeal life support (ECLS) - venoarterial extracorporeal membrane oxygenation - provides the strongest hemodynamic support in addition to oxygenation. However, despite increasing use it has not yet been properly investigated in randomized trials. Therefore, a prospective randomized adequately powered clinical trial is warranted. STUDY DESIGN: The ECLS-SHOCK trial is a 420-patient controlled, international, multicenter, randomized, open-label trial. It is designed to compare whether treatment with ECLS in addition to early revascularization with percutaneous coronary intervention or alternatively coronary artery bypass grafting and optimal medical treatment is beneficial in comparison to no-ECLS in patients with severe infarct-related cardiogenic shock. Patients will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoint of ECLS-SHOCK is 30-day mortality. Secondary outcome measures such as hemodynamic, laboratory, and clinical parameters will serve as surrogate endpoints for prognosis. Furthermore, a longer follow-up at 6 and 12 months will be performed including quality of life assessment. Safety endpoints include peripheral ischemic vascular complications, bleeding and stroke. CONCLUSIONS: The ECLS-SHOCK trial will address essential questions of efficacy and safety of ECLS in addition to early revascularization in acute myocardial infarction complicated by cardiogenic shock.

Troponins and Natriuretic Peptides in Cardio-Oncology Patients-Data From the ECoR Registry.

BACKGROUND: The long-term survival of cancer patients has significantly improved over the past years. Despite their therapeutic efficacy, various cancer therapies are associated with cardiotoxicity. Therefore, timely detection of cardiotoxic adverse events is crucial. However, the clinical assessment of myocardial damage caused by cancer therapy remains difficult. METHODS: This retrospective study was performed to evaluate the diagnostic value of cardiac troponin I (cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for monitoring cancer therapy-induced cardiomyopathy. A total of 485 cancer patients referred to our cardio-oncology unit between July 2018 and January 2020 were selected from our Essen Cardio-oncology Registry (ECoR). We included patients with all types of cancer. Plasma concentrations of cTnI and NT-proBNP were measured by radioimmunoassay, and two-dimensional left ventricular ejection fraction (2D-LVEF), diastolic function, and global longitudinal strain (GLS) were measured by transthoracic echocardiography. In 116 patients, assessment was conducted before the induction of cancer therapy and during a short-term follow-up period; n = 42 of these were treated for malignant melanoma, and n = 42 with serial measurements were under treatment for breast cancer. RESULTS: In cross-sectional data, elevated NT-proBNP was associated with reduced LVEF and pathological GLS in the total cohort. A total of 116 patients had serial LVEF and biomarker measurements, and changes in NT-proBNP and troponin correlated with changes in LVEF during follow-up investigations. Similar to the total cohort, a subgroup of patients treated for malignant melanoma showed a correlation between the change in cTnI and the change in LVEF. In a subgroup analysis of patients undergoing breast cancer therapy, a correlation between the change in NT-proBNP and the change in LVEF could be detected. Thirty patients presented with chemotherapy-induced cardiomyopathy, defined as a significant LVEF decrease (> 10%) to a value below 50%. The number of patients with increased cTnI and NT-proBNP was significantly higher in patients with chemotherapy-induced cardiomyopathy than in patients without cardiotoxicity. Patients with positive cTnI and NT-proBNP were more likely to have a history of coronary heart disease, atrial fibrillation, and arterial hypertension. CONCLUSION: Our data suggest that cardiac biomarkers play an important role in the detection of cancer therapy-induced cardiotoxicity. Larger systematic assessment in prospective cohorts is mandatory.

Comparison of Lipoprotein(a)-Levels in Patients ≥70 Years of Age With Versus Without Aortic Valve Stenosis.

Although lipoprotein(a) (Lp[a]) is linked with aortic valve calcification and clinical aortic valve stenosis (AVS) in middle-aged cohorts, patients aged ≥70 years represent a majority of patients with AVS, in which mechanisms leading to AVS may differ. We sought to determine whether Lp(a) distinguishes patients ≥70 years with and without AVS. We matched 484 patients ≥70 years with AVS, scheduled for transcatheter aortic valve implantation with 484 patients without AVS by age group and gender. Lp(a) levels were compared in patients with and without AVS and stratified by presence and absence of clinical coronary artery disease (CAD) manifestation. A total of 968 patients (mean age 80 ± 5 years, 48% women) were included. When comparing patients with and without AVS, no difference in Lp(a) was observed (AVS: 17 [8; 56] mg/dl, no AVS: 18.5 [8.5; 57] mg/dl, p = 0.56). In contrast, patients with clinical CAD manifestation had higher Lp(a) levels than those without clinical CAD manifestation (coronary artery disease: 19 [9; 60] mg/dl, no coronary artery disease 15 [7; 44] mg/dl, p = 0.0006). In regression analysis, no significant association of Lp(a) with AVS was observed in unadjusted (OR [95% CI]: 0.98 [0.91 to 1.06], p = 0.59) and risk factor-adjusted models (0.98 [0.90 to 1.06], p = 0.57). However, Lp(a) was independently associated with clinical CAD manifestation (unadjusted: 1.14 [1.04 to 1.24], p = 0.003, risk factor adjusted: 1.17 [1.07 to 1.27], p = 0.0006). In conclusion, in a large cohort of patients ≥70 years, Lp(a) was associated with clinical CAD manifesation, but not with AVS. Our results suggest that in patients over 70 years, the development of AVS is not influenced by Lp(a).

Cardiovascular imaging in cardio-oncology.

Cancer therapy may lead to cardiovascular complications and can promote each aspect of cardiac disease manifestation, such as vascular disease including coronary heart disease, myocardial diseases including heart failure, structural heart diseases including valvular heart diseases, and rhythm disorders. All potential complications of cancer therapy onto the cardiovascular system require imaging for diagnostic workup as well as monitoring of therapy. Transthoracic echocardiography (TTE) is the most frequently used tool for assessment of cardiac function during or after cancer therapy in daily clinical routine. With modern techniques like strain analysis, echocardiography allows to detect a variety of cardiac diseases as caused by cancer therapy even at subclinical stages. For further workup, specific imaging techniques including nuclear imaging are needed in a multimodality imaging approach to in detail characterize the underlying pathophysiology and to improve the management of the patients. Therefore, the field of imaging in cardio-oncology is rapidly growing. This review article will give an overview about existing literature regarding the role of imaging in the diagnostic evaluation and management of therapy in patient with prior or ongoing cancer therapy.

Impact of Preoperative Anemia and Postoperative Hemoglobin Drop on the Incidence of Acute Kidney Injury and In-Hospital Mortality in Patients With Type B Acute Aortic Syndromes Undergoing Thoracic Endovascular Aortic Repair.

BACKGROUND: The impact of preoperative anemia and postoperative hemoglobin (Hb) drop on the incidence of acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) for type B acute aortic syndromes (AAS) as well as their prognostic value is unknown. METHODS: This retrospective study included 144 patients with type B AAS undergoing TEVAR at our center. Preoperative anemia was classified as no/mild (Hb ≥ 12.0 g/dL in men; ≥11.3 g/dL in women), moderate (Hb 10.80-11.99 g/dL in men; 10.23-11.29 g/dL in women), and severe (<10.80 g/dL in men; <10.23 g/dL in women). Postoperative Hb drop was classified as mild (<2 g/dL), moderate (2-4 g/dL), and severe (>4 g/dL). End points of the study were postoperative AKI and in-hospital mortality. RESULTS: Postoperative AKI was higher in the severe and moderate anemia groups than the no/mild anemia group (63.2%, 52.0%, and 31.0%, respectively, P = .01). In-hospital mortality and AKI were higher in patients with severe postoperative Hb drop (40.9% and 86.4%) than patients with moderate (6.9% and 36.2%) and mild (4.7% and 25.0%) postoperative Hb drop (both P < .001). Postoperative Hb drop (odds ratio [OR]:1.67, P = .036), postoperative Hb levels (OR: 0.57, P = .025), and mesenteric ischemia (OR: 4.65, P = .044) were identified as independent predictors of in-hospital mortality. Preoperative Hb (OR: 0.26, P = .001), postoperative Hb drop (OR: 4.34, P < .001), contrast medium (OR: 1.82, P = .004), and diabetes mellitus (OR: 3.79, P = .001) were independent predictors of AKI. At follow-up, anemia and postoperative Hb drop were not associated with increased mortality. CONCLUSION: Preoperative Hb and postoperative Hb drop were significant risk factors for AKI. Postoperative Hb drop and Hb levels predicted in-hospital mortality.

Prevalence and Prognostic Implications of Coronary Artery Calcification in Low-Risk Women: A Meta-analysis.

Importance: The role of coronary artery calcium (CAC) testing for guiding preventive strategies among women at low cardiovascular disease (CVD) risk based on the American College of Cardiology and American Heart Association CVD prevention guidelines is unclear. Objective: To assess the potential utility of CAC testing for CVD risk estimation and stratification among low-risk women. Design, Setting, and Participants: Women with 10-year atherosclerotic CVD (ASCVD) risk lower than 7.5% from 5 large population-based cohorts: the Dallas Heart Study (United States), the Framingham Heart Study (United States), the Heinz Nixdorf Recall study (Germany), the Multi-Ethnic Study of Atherosclerosis (United States), and the Rotterdam Study (the Netherlands). The 5 cohorts were selected based on the availability of CAC data in a sizable group of low-risk women from the general population together with the long detailed follow-up data. Across the cohorts, events were assessed from the date of CAC scan (performed from 1998 through 2006) until January 1, 2012; January 1, 2014; or March 6, 2015. Fixed-effects meta-analysis was conducted to combine the results of the 5 studies. Exposures: CAC score by computed tomography. Main Outcomes and Measures: Main outcome was incident ASCVD, including nonfatal myocardial infarction, coronary heart disease (CHD) death, and stroke. Association of CAC with ASCVD was examined using Cox proportional hazards models. To assess whether CAC was associated with improved ASCVD risk predictions beyond the traditional risk factors, the C statistic and the continuous net reclassification improvement (cNRI) index were calculated. Results: Among 6739 women with low ASCVD risk from the 5 studies, mean age ranged from 44 to 63 years and CAC was present in 36.1%. Across the cohorts, median follow-up ranged from 7.0 to 11.6 years. A total of 165 ASCVD events occurred (64 nonfatal myocardial infarctions, 29 CHD deaths, and 72 strokes), with the ASCVD incidence rates ranging from 1.5 to 6.0 per 1000 person-years. Compared with the absence of CAC (CAC = 0), presence of CAC (CAC >0) was associated with an increased risk of ASCVD (incidence rates per 1000 person-years, 1.41 for CAC absence vs 4.33 for CAC presence; difference, 2.92 [95% CI, 2.02-3.83]; multivariable-adjusted hazard ratio, 2.04 [95% CI, 1.44-2.90]). The addition of CAC to traditional risk factors improved the C statistic from 0.73 (95% CI, 0.69-0.77) to 0.77 (95% CI, 0.74-0.81) and provided a cNRI of 0.20 (95% CI, 0.09-0.31) for ASCVD prediction. Conclusions and Relevance: Among women at low ASCVD risk, CAC was present in approximately one-third and was associated with an increased risk of ASCVD and modest improvement in prognostic accuracy compared with traditional risk factors. Further research is needed to assess the clinical utility and cost-effectiveness of this additional accuracy.

Clinical features and prognostic value of stent-graft-induced post-implantation syndrome after thoracic endovascular aortic repair in patients with type B acute aortic syndromes.

OBJECTIVES: The aim of this study was to investigate the incidence, the biomarker profile and the clinical impact of post-implantation syndrome (PIS) after thoracic endovascular aortic repair (TEVAR) for type B acute aortic syndromes (AASs). METHODS: This retrospective study included 133 patients with type B AASs undergoing TEVAR; PIS was defined as fever >38°C, white blood cells (WBCs) >12.0/nl and C-reactive protein (CRP) >10 mg/dl within 72 h after TEVAR, despite negative blood cultures. Fibrinogen (FBG), D-dimer (D-d) and interleukin 6 (IL-6) were also determined. The clinical endpoints were all-cause mortality and a composite of major adverse events (MAEs such as aortic rupture, need for reintervention and all-cause mortality) at follow-up. RESULTS: PIS was diagnosed in 15.8% of patients and was associated with higher peak values of WBC (17.0 ± 5.1 vs 10.6 ± 3.7/nl, P = 0.002), CRP (22.0 ± 5.4 vs 16.8 ± 8.2 mg/dl, P = 0.03), FBG (779 ± 246 vs 639 ± 225 mg/dl, P = 0.046), D-d (1675 ± 605 vs 1048 ± 639 µg/l, P = 0.003) and IL-6 (192 ± 101 vs 84 ± 34 pg/ml, P = 0.03) than non-PIS patients. All-cause mortality did not significantly differ between PIS and non-PIS patients during the index hospitalization (0.0 vs 6.3%; P = 0.60) and at follow-up (18.8 vs 4.9%; P = 0.086). MAEs were more frequent in the PIS than in the non-PIS group (62.5 vs 25.9%; P = 0.004). PIS (hazard ratio [HR] 3.26, P = 0.022), stroke (HR 3.41, P = 0.004), aortic enlargement (HR 6.88, P = 0.001) and partial thrombosis of the false lumen (HR 6.20, P = 0.003) were independent predictors of MAEs. CONCLUSIONS: PIS occurred in 15.8% of patients with AASs without affecting in-hospital outcome. At follow-up, PIS was associated with increased rates of MAEs, but not mortality.

10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study).

BACKGROUND: Several studies have demonstrated the tremendous potential of using coronary artery calcium (CAC) in addition to traditional risk factors for coronary heart disease (CHD) risk prediction. However, to date, no risk score incorporating CAC has been developed. OBJECTIVES: The goal of this study was to derive and validate a novel risk score to estimate 10-year CHD risk using CAC and traditional risk factors. METHODS: Algorithm development was conducted in the MESA (Multi-Ethnic Study of Atherosclerosis), a prospective community-based cohort study of 6,814 participants age 45 to 84 years, who were free of clinical heart disease at baseline and followed for 10 years. MESA is sex balanced and included 39% non-Hispanic whites, 12% Chinese Americans, 28% African Americans, and 22% Hispanic Americans. External validation was conducted in the HNR (Heinz Nixdorf Recall Study) and the DHS (Dallas Heart Study). RESULTS: Inclusion of CAC in the MESA risk score offered significant improvements in risk prediction (C-statistic 0.80 vs. 0.75; p < 0.0001). External validation in both the HNR and DHS studies provided evidence of very good discrimination and calibration. Harrell's C-statistic was 0.779 in HNR and 0.816 in DHS. Additionally, the difference in estimated 10-year risk between events and nonevents was approximately 8% to 9%, indicating excellent discrimination. Mean calibration, or calibration-in-the-large, was excellent for both studies, with average predicted 10-year risk within one-half of a percent of the observed event rate. CONCLUSIONS: An accurate estimate of 10-year CHD risk can be obtained using traditional risk factors and CAC. The MESA risk score, which is available online on the MESA web site for easy use, can be used to aid clinicians when communicating risk to patients and when determining risk-based treatment strategies.

Increased discordance between HeartScore and coronary artery calcification score after introduction of the new ESC prevention guidelines.

OBJECTIVES: The European HeartScore has traditionally differentiated between low and high-risk countries. Until 2012 Germany and Denmark were considered to be high-risk countries but have now been defined as low-risk countries. In this survey we aim to address the consequences of this downgrading. METHODS: A screening of 3932 randomly selected (mean age 56 years, 46% male) individuals from Germany and Denmark free of cardiovascular disease was performed. Traditional risk factors were determined, and the HeartScore was measured using both the low-risk and the high-risk country models. A non-contrast Cardiac-CT scan was performed to detect coronary artery calcification (CAC). RESULTS: Agreement of HeartScore risk groups with CAC groups was poor, but higher when applying the algorithm for the low-risk compared to the high-risk country model (agreement rate: 77% versus 63%, and weighted Kappa: 0.22 versus 0.15). However, the number of subjects with severe coronary calcification (CAC score ≥400) increased in the low and intermediate HeartScore risk group from 78 to 147 participants (from 2.7 % to 4.2 %, p = 0.001), when estimating the risk based on the algorithm for low-risk countries. CONCLUSION: As a consequence of the reclassification of Germany and Denmark as low-risk countries more people with severe atherosclerosis will be classified as having a low or intermediate risk of fatal cardiovascular disease.

B-type natriuretic peptide for incident atrial fibrillation-The Heinz Nixdorf Recall Study.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia and is associated with increased morbidity and mortality. Thus, identifying subjects with unknown AF or at higher risk for future AF in the general population is of importance. B-type natriuretic peptide (BNP) is linked with silent cardiac diseases. We evaluated the association of BNP with incident AF in a large population-based cohort study. METHODS: We included subjects from the population-based Heinz Nixdorf Recall study without known coronary heart disease, prior stroke, history of open heart surgery, heart-device therapy, or prevalent AF at baseline. Association of continuous and binary (≥31pg/ml for male, ≥45pg/ml for female) BNP with incident AF after 5 years was assessed using logistic regression analysis. RESULTS: A total of 3067 subjects (mean age 58.9 years, 47.9% male) were included in this analysis. Subjects with incident AF (n=42) had higher levels of BNP (median (Q1; Q3): 33.2pg/ml (19.4; 50.5) vs. 16.9pg/ml (9.2; 30.2)). Likewise, BNP was associated with incidence of AF both in univariate model and when adjusting for AF risk factors (odds ratio (OR) (95% confidence interval (CI)): BNP as continuous variable: 1.27 (1.09; 1.47), p=0.002; BNP as binary variable: 2.68 (1.41; 5.11) with AF risk factor adjustment). Notably, especially younger subjects (<60 years) showed stronger association with incident AF than older ones (OR (95%CI) for dichotomized BNP: 7.20 (1.60; 32.49), p=0.01 for <60 years, vs. 2.13 (0.89; 5.09), p=0.09 for 60-70 years, and 4.40 (1.29; 14.97), p=0.02 for >70 years). CONCLUSIONS: Elevated levels of BNP are associated with significant excess of incident AF, independent of traditional AF risk factors in the general population. Gender-specific BNP thresholds may help in prevention by detecting unknown or future AF, which carries a high risk of stroke events.

On the paradox of exercise: coronary atherosclerosis in an apparently healthy marathon runner.

BACKGROUND: An asymptomatic and apparently healthy 64-year-old marathon runner underwent comprehensive cardiovascular risk assessment as part of a prospective study on calcified coronary plaque burden in master marathon runners. His profile suggested a low 10-year cardiovascular risk. INVESTIGATIONS: Conventional risk-factor assessment, coronary artery calcium quantification, bicycle stress test, echocardiography, coronary angiography, intravascular ultrasonography, including virtual histology, and intracoronary Doppler ultrasonography. DIAGNOSIS: Severe coronary atherosclerosis of the left anterior descending, mid left circumflex, and left main arteries. MANAGEMENT: Stenting of the left anterior descending artery, CABG surgery, and intensive risk-factor modification. The patient was also advised against participating in future marathon competitions.