This article is more than 5 years old. Information may no longer be current.
Patients with anomalous aortic origin of a coronary artery return to exercise after surgery
A majority of patients with anomalous aortic origin of a coronary artery, including those with high-risk lesions, have been allowed to participate in unrestrictive exercise and sports activities, according to results presented at Cardiology 2017.
Anomalous aortic origin of a coronary artery is the second-leading cause of sudden cardiac death in young athletes in the United States.
“As of right now, these patients continue to be managed in different ways by different hospitals, and even in the same hospital by different providers,” Hitesh Agrawal, MD, pediatric cardiology fellow at Texas Children’s Hospital, Baylor College of Medicine, Houston, who presented the data, told Cardiology Today. “We have developed a uniform algorithm to evaluate these patients, because it can guide clinical decision making and help to collect meaningful clinical data to determine best practices and improve outcomes.”
Silvana Molossi, MD, PhD, FACC, associate professor of pediatrics-cardiology at Baylor College of Medicine and medical director, community and program development, cardiology at Texas Children’s Hospital, and colleagues prospectively analyzed data from 163 patients aged 20 years or younger with anomalous aortic origin of a coronary artery (AAOCA) from December 2012 to February 2017. Myocardial perfusion was assessed using stress imaging, which comprised of treadmill stress nuclear perfusion imaging and/or dobutamine stress cardiac MRI. CTA was performed to assess coronary anatomy.
Of the 163 patients aged 20 years or younger, 82 were considered high risk, defined by anatomical criteria and symptoms or evidence of myocardial ischemia. Predictors of high-risk lesions were older age at diagnosis, black race, presence of intramural course and syncope on exertion.
Of the total cohort, the majority of patients (approximately 80%) were allowed to participate in unrestrictive sports activities. Thus far, 46 patients had surgery and only two (4%) have remained restricted from sports activities. All patients were alive at a median follow-up of 1.6 years (interquartile range, 0.7-2.8).
“We want to try and get these patients back to sports and exercise as much as possible, because even exercise restriction is associated with negative, long-term physical and psychosocial health,” Agrawal told Cardiology Today. “If we just exercise-restrict all these patients, they are at risk for obesity in the long run. Obesity itself is a predictor for adverse [CV] events and mortality.
“A multi-institutional collaboration with a uniform algorithm can help to develop a risk scoring system like we have risk calculators for various diseases in adults [such as HF],” Agrawal told Cardiology Today. “It will be very helpful for evaluation and management of these patients across the world.” – by Darlene Dobkowski
Reference:
Molossi S, et al. Abstract 103. Presented at Cardiology: the 20th Annual Update on Pediatric and Congenital Cardiovascular Disease; Feb. 22-26, 2017; Orlando, Fla.
For more information:
Silvana Molossi, MD, PhD, FACC, can be reached at sxmoloss@texaschildrens.org.
Disclosure: Agrawal and Molossi report no relevant financial disclosures.
Perspective
Back to Top
The study stresses the importance of a consistent approach to these patients where there is significant inconsistency in how these patients are managed from center to center, and even among cardiologists at the same center. It is reassuring as well that most patients are not exercise-restricted without adverse outcomes.
It is encouraging to practitioners that exercise-restricting all patients is not necessarily the answer. Each patient should be looked at individually and assessed for their own potential risk.
It is hard to know whether patients’ outcomes would be different if they were placed on exercise restrictions, but I do not think so. The median follow-up time is quite short. We will have more answers once we have follow-up times in the range of 10 years or more.
More research is needed into ways to risk-stratify patients, notably those asymptomatic patients with anomalous right coronary artery, so we truly know who is at high risk for an adverse event. Many patients are found serendipitously and would never have known of the coronary anomaly had an echocardiogram not been performed; for example, a screening echocardiogram due to family history of congenital heart disease.
The major question with these patients is how or are we able to predict their future risk for an adverse event? Up to 0.7% of the population has AAOCA, and the vast majority go through life without any issues. We really need to figure out which subset of patients are the at-risk ones and treat them appropriately.
Continued collaboration between centers is so important in order to obtain larger patient numbers. This will help us to learn more about the natural history of the coronary anomaly, which will also help us with understanding risk. A multidisciplinary and team-focused approach is also very important for consistency.