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Sports_AnomCoronary_Overview_tofix.html
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<!DOCTYPE html>
<html lang="en">
<!-- defines the default zoom for mobile devices -->
<meta name="viewport" content="width=device-width, initial-scale=1" />
<head>
<meta charset="UTF-8">
<title>CardioRef: AHA/ACC 2015 Sports Participation Selector Guide: Anomalous Coronary Artery Origin</title>
<link rel="stylesheet" href="css/sports_answer_combined.css">
<style>
div{
-webkit-margin-before:0;
-webkit-margin-after:0;
-webkit-margin-start:0;
-webkit-margin-end:0;
}
</style>
</head>
<body>
<div class="topbar">
<a href="index.html">Pedi CardioRef</a>
<div class="guidelinebar">
<a target="_blank" rel="noopener noreferrer" href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000240">
Reference: ACC/AHA Sports Participation Recommendations (Circulation 2015) Task Force 4: Congenital Heart Disease</a>
</div>
</div>
<section style="margin:10px">
<p class="topspace"></p>
<label><b>By the ACC/AHA 2015 guidelines, should my patient with</label>
<select name="disease" id="dz" class="InputBox" onChange="goThere();">
<option value="">*Select Disease*</option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="HCM">Hypertrophic Cardiomyopathy </option>
<option value="LVNC">Left Ventricular Non-Compaction </option>
<option value="DilRestr">Dilated or Restrictive Cardiomyopathy </option>
<option value="ARVC">Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) </option>
<option value="Myo">Myocarditis </option>
<option value="Peri">Pericarditis </option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="ASDVSDPDA">ASD, VSD, or PDA </option>
<option value="PS">Pulmonic Stenosis </option>
<option value="AS">Aortic Stenosis </option>
<option value="Coarct">Coarctation </option>
<option value="Cyan">Cyanotic Heart Disease, unrepaired or with palliative shunt </option>
<option value="TOF">Tetralogy of Fallot, s/p repair </option>
<option value="TGA_Must">d-transposition (d-TGA), s/p atrial switch (Mustard/Senning)</option>
<option value="TGA_Art">d-transposition (d-TGA), s/p arterial switch </option>
<option value="CCTGA">Congenitally-corrected TGA (CC-TGA, L-TGA)</option>
<option value="Fontan">Fontan </option>
<option value="Ebstein">Ebstein Anomaly </option>
<option value="AnomCoronary">Anomalous Coronary Artery Origin</option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="PVR">Elevated PVR in CHD </option>
<option value="VentricularDysfxn">Ventricular Dysfunction s/p CHD Surgery</option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="Valve_AS">Aortic Stenosis</option>
<option value="Valve_AR">Aortic Regurgitation </option>
<option value="Valve_MS">Mitral Stenosis</option>
<option value="Valve_MR">Mitral Regurgitation </option>
<option value="Valve_Hx">History of Mitral or Aortic Valve Surgery</option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="HTN">Hypertension </option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="AoDiseases_and_Marfan">Aortic Diseases and Marfan Syndrome</option>
<option value="BAV">Bicuspid Aortic Valve</option>
<option value="Marfan">Marfan Syndrome</option>
<option value="TAA">Thoracic Aortic Aneurysm, familial or unexplained</option>
<option value="LoeysDietz_EhlersDanlos">Loeys-Dietz or vascular Ehlers-Danlos</option>
<option value="AoEnlarge">Enlarged Aorta, non-syndrome non-familial</option>
<option value="Ao_Surgery">S/p Surgery for Aortic Enlargement/Dissection</option>
<option value="Chronic_AoDissection">Chronic Aortic Dissection or Branch Aneurysm</option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="CoronaryOverview">Coronary Artery Disease </option>
<option value ="" class="dropdown-divider">---------------------------------------------------------------</option>
<option value="Syncope">Syncope </option>
<option value="Arrhythmia">Arrhythmias (SVT, PVC, Vtach, etc.) </option>
<option value="ConductionDefect">Conduction Defects (AV block, brady, pacemaker, RBBB/LBBB)</option>
<option value="Channelopathies">Channelopathies (LQTS, CPVT, Brugada, etc.) </option>
<option value="ICD">Implantable Cardioverter-Defibrillator (ICD) </option>
</select>
<span>participate in organized sports?</span></b>
<br><br>
<section id="question">
Should my patient with <b>Anomalous Coronary Artery Origin</b> participate in organized sports?
</section>
</section>
<br>
<section id="needtoknow">
<p class="sectiontitle">Need to know:</p>
<ul>
<li>Which coronary artery has anomalous origin</li>
<li>Origin of anomalous coronary (pulmonary artery vs. L sinus vs. R sinus)</li>
</ul>
</section>
<div class="multi">
<ul class="tabs">
<li class="tab">
<input type="radio" name="tabs" checked="checked" id="tab1" />
<label for="tab1">Overview</label>
<div id="tab-content1" class="content">
<h1>Overview</h1>
<hr>
<p>"Anomalies of coronary arteries are second in frequency among identified structural causes of SCD in competitive athletes, accounting for ≈17% of such deaths in the United States.44 Anomalous origins of coronary arteries from the wrong sinus of Valsalva or from the pulmonary artery are estimated to be present in ≈1% of the overall population45 but are proportionately far more common in athletes who die suddenly, as cited above. Although the vast majority of sudden deaths associated with coronary anomalies occur during or shortly after exercise,46 sudden death has been reported in the sedentary state.47
</p><p>
The most common anomalous origin is the right coronary artery originating from the left sinus of Valsalva, but among athletes who have died suddenly, anomalous origin of the left main or left anterior descending coronary artery from the right sinus of Valsalva is far more prevalent. Furthermore, SCDs are most strongly associated with the pattern in which the anomalous left coronary artery passes between the aorta and main pulmonary artery. An anomalous origin of a coronary artery from the pulmonary artery is far less commonly observed in athletes who die suddenly and in fact often presents with myocardial infarction in infancy or early childhood. Nonetheless, some cases are not recognized until adolescence or adulthood and may be associated with sudden death in athletes, albeit rarely. Nonspecific electrocardiographic findings may be observed in adolescents with otherwise unrecognized anomalous coronary arteries arising from the pulmonary artery.
</p><p>
The ECG is an unreliable screening tool for suspecting or recognizing anomalous origin of coronary arteries before an event, and even stress tests are not uniformly positive among people with these anomalies.48 Clinical symptoms, such as exertional chest discomfort or dyspnea, may be helpful, but 2 reports suggest that 50% of SCDs associated with coronary artery anomalies were first events without prior symptoms.46,49 The best methods for identifying the anomaly include coronary angiography, computed tomography angiography, and magnetic resonance angiography. Although not uniformly successful, athletes undergoing echocardiographic studies for any reason should have careful attempts to identify the origins of the coronary arteries.
</p><p>
Surgical procedures are the only therapies available for correcting these anomalies,50 with return to intense athletic activities permitted after 3 months after the procedure with demonstration of the absence of ischemia on postoperative stress testing.51"</p>
</p>
</div>
</li>
<li class="tab">
<input type="radio" name="tabs" id="tab2" />
<label for="tab2">ALCAPA/ARCAPA</label>
<div id="tab-content2" class="content">
<h1>ALCAPA or ARCAPA</h1>
<hr>
<section id="answer">
<section class="single_center">
<p class="sectiontitle">Prior to ALCAPA/ARCAPA repair</p>
<p>"Athletes with anomalous origin of a coronary artery from the pulmonary artery can participate only in
low-intensity class IA sports, whether or not they have had a prior myocardial infarction,
and pending repair of the anomaly (Class I Recommendation; Level of Evidence C)."
</p>
<div class="verdict_ok"><b>Only Class IA sports</b></div>
<br>
</section>
<p class="arrowsdouble"> ⇓ </p>
<section class="single_center">
<p class="sectiontitle">After ALCAPA/ARCAPA repair</p>
<p>
"After repair of anomalous origin of a coronary artery from the pulmonary artery,
decisions regarding exercise restriction may be based on presence of sequelae such as
myocardial infarction or ventricular dysfunction (Class IIb Recommendation; Level of Evidence C)."
</p>
<div class="verdict_maybe"><b>Conditional</b> (see above)</div><br>
</section>
</section>
</div>
</li>
<li class="tab">
<input type="radio" name="tabs" id="tab3" />
<label for="tab3">R coronary from L sinus</label>
<div id="tab-content3" class="content">
<h1>Right coronary artery from left sinus of valsalva</h1>
<hr>
<section id="needtoknow">
<p class="sectiontitle">Need to know:</p>
<ul>
<li>Whether coronaries have been repaired</li>
<li>Symptoms</li>
<li>Arrhythmias</li>
<li>Stress test results</li>
</ul>
<br>
</section>
<section id="answer">
<section id="answer_arrow_section">
<section class="third_invisible">⇙</section>
<section class="third_invisible"> ⇓ </section>
<section class="third_invisible">⇘</section>
</section>
<!-- <section id="answer">
<section id="answer_arrow_section">
<section class="third_left">↙</section>
<section class="third_middle">↓</section>
<section class="third_invisible">↘</section>
</section> -->
<section class="third_left">
<p class="sectiontitle">Unrepaired, asymptomatic, negative exercise stress test</p>
<p>"Athletes with an anomalous origin of a right coronary artery from the left sinus of Valsalva should be evaluated
by an exercise stress test. For those without either symptoms or a positive exercise stress test,
permission to compete can be considered after adequate counseling of the athlete and/or the
athlete’s parents (in the case of a minor) as to risk and benefit, taking into consideration the
uncertainty of accuracy of a negative stress test (Class IIa Recommendation; Level of Evidence C)."
</p>
<div class="verdict_maybe"><b>Conditional</b> (see above)</div>
<br>
</section>
<section class="third_middle">
<p class="sectiontitle">Unrepaired, symptomatic, arrythmias, ischemia on stress test</p>
<p>
"Nonoperated athletes with an anomalous origin of a right coronary artery from the left sinus of Valsalva
who exhibit symptoms, arrhythmias, or signs of ischemia on exercise stress test should be restricted from
participation in all competitive sports, with the possible exception of class IA sports,
before a surgical repair (Class III Recommendation; Level of Evidence C)."
</p>
<div class="verdict_no">No sports, possible exception Class IA</div><br>
</section>
<section class="third_right">
<p class="sectiontitle">After successful repair > 3 months ago, asymptomatic, negative stress test</p>
<p>
"After successful surgical repair of an anomalous origin from the wrong sinus,
athletes may consider participation in all sports 3 months after surgery if the patient remains
free of symptoms and an exercise stress test shows no evidence of ischemia or cardiac arrhythmias
(Class IIb Recommendation; Level of Evidence C)."
</p>
<div class="verdict_ok"><b>May consider all sports, if conditions met.</b> (Class IIb recommendation)</div><br>
</section>
</section>
</div>
</li>
<li class="tab">
<input type="radio" name="tabs" id="tab4" />
<label for="tab4">L coronary from R sinus</label>
<div id="tab-content4" class="content">
<h1>Left coronary artery from right sinus of valsalva</h1>
<hr>
<section id="answer">
<section class="single_center">
<p class="sectiontitle">Prior to repair</p>
<p>"Athletes with an anomalous origin of a left coronary artery from the right sinus of Valsalva,
especially when the artery passes between the pulmonary artery and aorta, should be restricted
from participation in all competitive sports, with the possible exception of class IA sports,
before surgical repair. This recommendation applies whether the anomaly is identified as a consequence of
symptoms or discovered incidentally (Class III Recommendation; Level of Evidence B)."
</p>
<div class="verdict_no"><b>No sports, possible exception Class IA</b></div>
<br>
</section>
<p class="arrowsdouble"> ⇓ </p>
<section class="single_center">
<p class="sectiontitle">After successful repair > 3 months ago, asymptomatic, negative stress test</p>
<p>
"After successful surgical repair of an anomalous origin from the wrong sinus, athletes may consider participation
in all sports 3 months after surgery if the patient remains free of symptoms and an exercise stress test shows
no evidence of ischemia or cardiac arrhythmias (Class IIb Recommendation; Level of Evidence C)."
</p>
<div class="verdict_ok"><b>May consider all sports, if conditions met.</b> (Class IIb recommendation)</div><br>
</section>
</section>
</div>
</li>
</ul>
</div>
<p class="foot">
<b>Reference:</b> <a href="https://www.ahajournals.org/doi/10.1161/CIR.0000000000000240"><i>Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease.
A Scientific Statement From the AHA and ACC.</i></a> <i>Circulation 2015</i>
<br><br><b>Disclaimer:</b> This website is derived from published guidelines, but does not constitute medical advice nor does it replace clinical judgement. Only the text in quotation marks are direct quotations from the original guidelines. Text not in quotations as well as the method of information display are all that of the website creator and are not part of the original published guidelines. Please consult a physician to discuss any patient-specific matters.
</p>
<section class="key">
<p><b>Key:</b> ALCAPA = anomalous left coronary artery from pulmonary artery, ARCAPA = anomalous right coronary artery from pulmonary artery, R = right, L = left, sinus = sinus of valsalva
</p>
</section>
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