The role of cardiac computed tomography in sports cardiology: back to the future! 

Abstract

In recent years, the role of pre-participation evaluation (PPE) in the prevention of sudden cardiac death in competitive athletes has become evident. Most physicians routinely supplement assessment by resting electrocardiogram with imaging techniques, such as echocardiography. The primary goal of imaging in the clinical assessment of competitive athletes is to exclude cardiovascular conditions associated with adverse outcomes. Cardiac computed tomography is emerging as an important technique for stratifying cardiovascular risk and assessing coronary artery disease (CAD), particularly in master athletes. Conversely, in young athletes, this technique has the best non-invasive coronary artery resolution and provides valuable details on coronary artery anatomy. Recent technical developments have brought about a dramatic reduction in radiation exposure, a major drawback of this diagnostic method; nowadays cardiac computed tomography may be performed at a dose of barely one millisievert. The present review provides a practical guide for the use of cardiac computed tomography in the PPE of competitive athletes, with a specific focus on its value for detecting congenital coronary anomalies and CAD in young and master athletes, respectively.

Graphical Abstract

The figure summarizes the clinical information that can be obtained by coronary computed tomography in sports cardiology, highlighting the differences between young and master athletes.

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Introduction

In recent years, the role of pre-participation evaluation (PPE) in the prevention of sudden cardiac death (SCD) in competitive athletes has become evident. Beyond controversies regarding the sensitivity and specificity of individual tests, cost-effectiveness, and the availability of expertise, most physicians not only use 12-lead resting electrocardiogram (ECG) but also imaging techniques, especially echocardiography, as first-line screening tools for athletes.¹ The primary goal of imaging in the clinical assessment of competitive athletes is to exclude cardiovascular conditions associated with adverse outcomes. Imaging assessment also plays an important role in risk stratification and surveillance after diagnosis of cardiovascular disease. Although the best method and the effectiveness of cardiovascular screening remain controversial, echocardiography is a cornerstone and the most widely used imaging tool for PPE. However, advanced imaging techniques, such as cardiac magnetic resonance imaging (MRI) and coronary computed tomography angiography (cCTA), are increasingly used in the cardiac evaluation of athletes. Specifically, cCTA gives the best non-invasive coronary artery resolution and provides valuable details of coronary artery anatomy in young athletes.² In athletes aged older than 35 years, cCTA is emerging as useful in cardiovascular risk stratification and assessment of coronary artery disease (CAD),³ since the conventional methods used for PPE of veteran athletes are poor at identifying significant subclinical CAD.⁴ Compared with other techniques, cCTA is currently underused in PPE, due to the issue of radiation exposure, especially in young subjects, and the lack of a well-defined role in screening competitive athletes. The present review provides a practical guide for the use of cCTA in the evaluation of competitive athletes, with a specific focus on its value for detecting CAD and congenital coronary anomalies (CCAs) in master and young athletes.

CAD in athletes

Although prolonged moderate-to-vigorous intensity exercise has clearly been associated with a reduced incidence of adverse events from CAD, the possible natural progression of coronary atherosclerosis to clinically significant stenoses has also been reported in athletes. While SCD in young athletes is usually induced by a genetic or congenital structural cardiac disorder, in athletes aged older than 35 years, more than 80% of all SCDs are due to acute coronary syndromes precipitated by pre-existing coronary atherosclerosis.^4–6 The aim of PPE in master athletes should therefore be to stratify cardiovascular risk and to detect CAD.

Coronary CTA is currently the non-invasive technique of reference for coronary assessment and for detailed plaque description.⁷ Interestingly, in the last 10 years, this technique has also been applied to athlete evaluation, especially for the quantification of coronary artery calcium (CAC) score.^8,9 It was recently demonstrated by cCTA that active middle-aged male athletes with high lifelong exercise volume have calcified coronary atherosclerosis associated with good outcome.¹⁰ Non-invasive coronary assessment with cCTA also demonstrated that the atherosclerotic profile differs substantially between master endurance athletes, who usually mainly show calcified lesions, and matched sedentary controls, who show a prevalence of fibrofatty or mixed plaque.⁹ Why master athletes show this difference is unknown. Endothelial damage from increased shear stress forces during exercise due to hyper-dynamic coronary circulation, mechanical bending of the coronary arteries during vigorous cardiac contraction, exercise-associated hypertension, generation of oxygen free radicals, and a systemic inflammatory response from repeated bouts of intensive exercise have all been suggested as possible factors.^9,11 Moreover, acutely high parathyroid hormone concentrations produced by exercise may accelerate coronary calcification in master athletes.^9,12 Indeed, intense physical activity increases circulating inflammatory markers and parathyroid hormone release.¹³ Clinical biomarkers, such as cardiac troponins (cTns), can increase acutely during exercise in healthy subjects, and although in clinical practice, cTn is usually assayed to assess myocardial ischaemia, a clear association between exercise-induced cTn increase and significant CAD has not been clearly demonstrated.¹⁴

From a prognostic perspective, although master athletes show longevity and a low prevalence of SCD,¹⁵ a significant increase in cardiovascular risk and mortality with the highest intensive levels of exercise has been suggested.¹⁶ In this regard, CAC score reclassifies risk in fit individuals, with an ∼2-fold increase in SCD for CAC scores >400 compared with fit individuals with CAC scores of zero¹⁵ (Figure 1). The concept of the relatively ‘benign’ prognostic implications of coronary calcifications in master athletes was strengthened by the observation of clinical outcomes in 21 758 men with a mean age of 51 over a mean follow-up of more than 10 years in the Cooper Centre Longitudinal Study.¹⁷ In this study, a weak association between all-cause mortality and CAC was described. Obviously, prospective multicentre studies with long-term follow-up are needed to further test this hypothesis.

According to these results, CCT (either CAC score or cCTA) is emerging as an outstanding non-invasive imaging technique for evaluating atherosclerosis in master athletes, from both diagnostic and prognostic perspectives. The implementation of this imaging technique in PPE, especially in the case of master endurance athletes, is a matter of current debate. Although current guidelines recommend the use of 12-lead resting ECG to screen athletes, a recent survey demonstrated that imaging techniques, particularly echocardiography and cardiac MRI, are frequently used by physicians as a first-line screening tool for athletes.¹ Since standard cardiac screening protocols are often inadequate in the prevention of acute cardiovascular events in athletes aged older than 35 years,¹⁸ the identification of CAD in master athletes is seen by many sport physicians as an urgent need, despite the fact that there is currently insufficient evidence to support the introduction of cCTA in PPE of asymptomatic master athletes.¹⁹ To date, only small retrospective single-centre studies or case series are available, from which it emerges that cCTA may be useful in the evaluation of master athletes in specific settings, such as after abnormal stress test results or if clinical suspicion is raised by factors such as age, sex, symptoms, or risk-SCORE assessment^20,21 (Figure 2).

If future studies confirm that cCTA is useful for reducing ischaemic causes of SCD in master athletes, cCTA will be more commonly implemented during PPE, particularly in high-level professional and endurance athletes and in asymptomatic master athletes at high risk for CAD with equivocal stress tests or mild symptoms.

The central illustration summarizes the clinical information that can be obtained by coronary computed tomography in sports cardiology, highlighting the differences between young and master athletes.

Detection of ischaemic heart disease by imaging: pros and cons

Different diagnostic techniques are available for non-invasive detection of chronic coronary syndromes. All have proper indications, as well as advantages and disadvantages, and can be divided into non-invasive anatomical and functional tests. The first group includes cCTA, whereas functional tests include: exercise ECG testing, cardiopulmonary exercise testing, stress echocardiography, cardiac single-photon emission CT (SPECT), positron emission tomography (PET), and stress cardiac magnetic resonance (CMR). The choice is based on chronic coronary syndrome pre-test probability estimation, defined as the likelihood of obstructive CAD on the basis of symptoms, age, and sex.⁷ Coronary CTA is mainly indicated in patients with low and low-to-intermediate pre-test probability and no previous diagnosis of CAD; its main purpose is to rule out significant atherosclerosis. It allows coronary assessment and detailed plaque description. Its use could be limited by the presence of non-sinus rhythm, high heart rate, obesity, dense calcification, the inability of a patient to collaborate, and cost and radiation exposure,²² although latest-generation scanners solve most of these limitations.²³ Coronary CTA can be combined with CT functional assessment, such as CT-derived fractional flow reserve (CT-FFR) analysis and stress CT perfusion, to combine functional and anatomical information.^24,25 Unfortunately, the availability of these techniques is still limited. Due to its poor sensitivity and specificity, exercise ECG testing has limited indications in current practice, although it is widely used in athletes. Exercise tolerance, blood pressure response to exercise, arrhythmias, and symptom threshold can be evaluated during the test, whereas ECG interpretation is limited in cases of branch blocks, pre-excitation syndrome, pacemakers, abnormal resting ECG, and digitalis treatment.²⁶ Commonly used in sports cardiology, particularly in prescribing exercise, cardiopulmonary exercise testing combines integrated blood gas analysis with parameters commonly evaluated during exercise ECG testing, making it possible to detect cardiac, ventilatory, and metabolic response to physical activity and exercise-induced ischaemia, the latter via graphs of oxygen pulse and VO₂ in relation to work rate (ΔVO₂/ΔWR) that prematurely flatten or decline,^27–30 resulting in greater sensitivity and specificity than exercise ECG testing, particularly in master athletes.²⁹ Limitations are the need to calibrate before each test and to wear a face mask, the cost of equipment, and the need for experienced cardiologists to interpret the results.²⁹ Stress echocardiography (with exercise and pharmacological stress) is indicated for assessing inducible myocardial ischaemia in patients with intermediate-to-high pre-test probability and CAD, or with unclear cCTA results, allowing real-time assessment of global and segmental heart function. Because exercise echocardiography preserves the physiological electromechanical response to exercise and reproduces a typical maximum effort, it is preferred to the pharmacological test in athletes. In elite endurance athletes, where exercise-induced left ventricular (LV) enlargement is associated with mild systolic impairment, exercise stress echocardiography provides further insights for assessment of cardiac function normalization during stress, as well as heart valve function, pulmonary pressure, and diastolic function, distinguishing athletes’ heart from pathological conditions.³¹ The main limitations of stress echocardiography are the poor acoustic window and the fact that it is impossible to characterize coronary artery anatomy. SPECT is a nuclear imaging technique that combines physical or pharmacological stress with different tracers and with different protocols tailored to the patient.³² It can be performed in patients with intermediate, high-intermediate, and high pre-test probability and also allows identification of ischaemic coronary territories together with functional evaluation. SPECT requires a stable ECG for gating. Its sensitivity and specificity may be reduced in obese patients, females with abundant breasts, or in patients with diffuse reduction of myocardial perfusion reserve. PET provides non-invasive in vivo quantification of myocardial blood flow using tracers and ensures better image quality than SPECT, as well as absolute quantification of myocardial perfusion. Its main limitation is the need for an on-site cyclotron or generator with the tracer. Stress perfusion CMR using vasodilator stressors, coupled with late gadolinium enhancement assessment and mapping techniques, has shown high accuracy for the diagnosis of significant CAD;^33–35 however, high operator training is required for reliable image interpretation, and there is still limited availability of scanners. Table 1 summarizes the main pros and cons of the different non-invasive imaging techniques in the context of chronic coronary syndromes, showing the performance of non-invasive tests to rule in and rule out significant coronary artery stenosis (adapted from Knuuti et al.³⁶).

Coronary artery origin abnormalities

Coronary artery origin abnormalities and SCD

CCAs are a heterogeneous group of malformations whose prevalence in the general population is estimated by angiographic studies at around 1–2%, being even higher, around 5%, in studies performed with cCTA.^37,38 The two main groups of CCA are as follows: (i) anomalies of origin and distribution of the coronary arteries (87%) and (ii) coronary fistulae (13%). The latter group includes some clinically significant conditions associated with symptoms such as typical angina, syncope, pre-syncope, and chest discomfort.¹Figure 3 shows an example of a complex fistula in a competitive athlete.

Coronary artery origin abnormalities are divided into benign and potentially malignant anomalies on the basis of autopsy, pathophysiological, and clinical features. These anomalies are often discovered incidentally, but they can also play a role in SCD of young athletes.^39–44 Indeed, a study on the epidemiology of sudden death in young US competitive athletes showed that CCA was the second cause of SCD after hypertrophic cardiomyopathy,⁴⁵ whereas a study performed in athletes of US National Collegiate athletic associations identified CCA as the first cause of SCD.⁴⁶ CCAs as a cause of SCD have also been described in adolescents and young athletes in Europe, and CCA with a coronary artery originating from the wrong coronary sinus has been associated with the highest risk of sports-related SCD [relative risk (RR) = 79, P < 0.0001], followed by arrhythmogenic right ventricular cardiomyopathy (RR = 5.4, P < 0.001) and premature CAD (RR = 2.6, P = 0.008).⁴¹

Clinically, patients with ‘malignant’ CCA may complain of typical angina but most have atypical symptoms such as syncope, pre-syncope, chest discomfort, dyspnoea, palpitations, or may be fully asymptomatic, cardiac arrest being the first manifestation of the anomaly.⁴⁷ Note that syncope in athletes may have causes other than CCA, such as non-cardiac and cardiac causes (e.g. arrhythmias, cardiomyopathy, channelopathies, LV scar). An integrated multimodal approach is therefore essential for differential diagnosis and to evaluate for an underlying life-threatening cardiovascular disease, as suggested in a recently published algorithm designed to rule out cardiac causes of syncope in athletes.⁴⁸

Diagnostic testing to detect coronary artery origin abnormalities

Exercise ECG may show ST-segment depression suggesting myocardial ischaemia, but is more often negative or shows non-specific findings, whereas 12-lead resting ECG performed as per protocol in the PPE of competitive athletes is not informative. Conversely, echocardiography is considered a reliable non-invasive technique for detecting such anomalies,⁴⁹ when appropriate examinations are performed. Echocardiography is an inexpensive ‘green’ imaging technique that does not expose young athletes to radiation. Pioneering studies in competitive athletes have demonstrated that visualization of the ostia and first tracts of both coronary arteries can be obtained by echocardiography in 90% of cases.^49–51 However, echocardiography has some limitations and does not allow coronary ostia identification in 100% of cases due to technical issues, such as interference by the ribs and lungs, the high heart rate of young subjects, and the poor acoustic window in some individuals. Notably, the identification of coronary origin abnormalities depends on the expertise of the operator. The advent of cCTA has radically changed the approach to the diagnosis and management of CCA; indeed, cCTA is the most accurate non-invasive imaging technique in this field³⁸ and has been demonstrated to provide essential information for safe and effective clinical management of athletes, with significant prognostic implications.⁵²

CCAs include all conditions in which one or more coronary branches originate differently from what is considered to be normal anatomy. Abnormal origins of a coronary artery may be as follows: (i) from the pulmonary artery: in this case, myocardial perfusion depends completely on the coronary which arises from the aorta and also supplies the anomalous coronary. This form is very uncommon in athletes because in more than 80% of cases it is associated with severe symptoms that limit physical activity. A posterior course between the aorta and low-pressure atrium is not associated with SCD.^40,53 (ii) From the aorta but from the ‘wrong’ coronary sinus of Valsalva [origin of the right coronary artery (RCA) from the left sinus or from the left coronary artery (LCA) and vice versa], with a prevalence of around 0.2–0.7% in the general population.^53,54 These anomalies can be a ‘benign’ incidental finding, but can also lead to severe complications, being the second cause of SCD in young athletes in the US⁴² and the third cause in Italy.⁴¹ Note that the estimated relative risk of SCD in athletes vs. non-athletes with such anomalies is 79-fold higher, indicating that vigorous exertion is the main factor in precipitating cardiac arrest.⁴¹

The most common anomaly is an RCA arising from the left sinus of Valsalva or the LCA (AORCA, Figure 4), whereas an LCA arising from the right sinus of Valsalva or from the RCA (AOLCA, Figure 5) is associated with a greater risk of SCD.⁵⁵ As reported by Cheezum et al.³⁸, the anomalous coronary artery has several potential ‘paths’ to its perfusion territory from the abnormal ostial position: (i) pre-pulmonic: anterior to the right ventricular outflow tract; this is usually a benign form with no haemodynamic consequences; (ii) retro-aortic: posterior to the aortic root, passing between the posterior sinus of Valsalva and the interatrial septum, where there are normally no vascular structures; this is not usually haemodynamically significant; (iii) inter-arterial: passing between the aorta and pulmonary artery; this variant is associated with the highest risk of ischaemia and SCD, especially when the proximal tract of the anomalous vessel enters the aortic wall (intra-mural or intra-adventitial path); (iv) trans-septal: the affected coronary artery takes a sub-pulmonic path, passing anteriorly and inferiorly through the interventricular septum, then an intramyocardial path whence it emerges in its normal epicardial position; cCTA is the best technique for distinguishing trans-septal and inter-arterial pathways; (v) retro-cardiac: in this case, the anomalous coronary artery passes behind the mitral and tricuspid valves, in the posterior AV groove; the clinical significance of this anomaly is unclear.

Finally, it is worth mentioning an abnormal origin of a coronary above the aortic cusps or above the sino-tubular junction (high origin, high take-off), the clinical significance of which is unclear.⁵⁶ Although most of these patients are asymptomatic, some have typical or atypical angina during exercise, even in the absence of coronary atherosclerotic disease, and a minority of cases may even suffer SCD.^39,40

Regarding SCD in the young, the most ‘malignant’ variant is AOLCA, especially if the vessel lies between the pulmonary trunk and anterior segment of the aorta (inter-arterial course) and/or there is a proximal intra-mural or intra-adventitial tract. However, cases of SCD and resuscitated cardiac arrest during exercise are also reported in patients with AORCA.^39,57 An incidence of coronary-related SCD of 0–57% for AORCA and 27–100% for AOLCA was recently described.³⁸ In line with these findings, the 2015 ACC/AHA scientific statement for competitive athletes with cardiovascular abnormalities suggested that AOLCA patients should not take part in competitive sports, regardless of their symptoms and that AORCA patients should not take part in competitive sports before surgical repair, if they manifest symptoms, arrhythmias, or signs of ischaemia during exercise testing.⁵⁸ Similarly, according to the recently published ESC guidelines, participation in competitive sports (except low-intensity skill sports) is restricted for athletes with anomalous origin of coronary arteries featuring acute-angled take-off from the aorta resulting in a slit-like orifice with a reduced lumen and an anomalous path between the aorta and the pulmonary artery. The highest risk factor for ischaemia and SCA/SCD is an anomalous coronary artery originating from the left or right sinus of Valsalva. The possibility of surgical correction of this anomaly should be assessed in symptomatic individuals.²¹ Conversely, for asymptomatic individuals with CCA, where the affected artery does not lie between the large vessels, does not have a slit-like orifice with reduced lumen, and/or does not have an intra-mural segment, competition may be contemplated after adequate counselling on the risks, in the absence of inducible ischaemia (Class IIb).²¹

The mechanisms of ischaemia are not completely clear, but they are probably mostly anatomy-dependent and can coexist in the same subject: (i) acute take-off angle (<45°) of the anomalous artery with functional closure, i.e. a ‘slit-like’ orifice; (ii) compression of the anomalous artery between the aorta and the pulmonary trunk or obliteration of the lumen and expansion of the aorta during exercise, especially if the first segment is hypoplastic and/or has an intra-mural/intra-adventitial tract. Additional factors could be the length and diameter of the intra-mural segment, which can explain why patients with apparently similar anatomy have different clinical profiles and risk.^38,47,59

In this context, cCTA is undoubtedly useful for identifying these coronary abnormalities and preventing SCD in competitive athletes. It was recently considered the best imaging technique for defining anatomical details of CCAs and useful for risk stratification and clinical management,³⁸ showing advantages for CCA characterization with respect to invasive coronary angiography.⁶⁰ When compared with alternative non-invasive or invasive imaging techniques, the major strengths of cCTA are considered to be non-invasiveness, rapidity, comprehensive visualization of take-off, path and surrounding structures, concomitant assessment of CAD, and full evaluation of multiple CCA features.² Detailed CT-derived malignancy criteria have also been described, i.e. minimum lumen area ≤4 mm², area stenosis ≥50%, intra-arterial tract length >10 mm, and length of narrowing >5.4 mm.^61,62

Coronary artery course abnormalities: myocardial bridging

Coronary course anomalies most commonly involve the left anterior descending artery (LAD) but can also be found in the left circumflex artery (CFx) and in the RCA. They concern an anomalous intramyocardial or subendocardial path that may have a haemodynamically significant impact.⁶³ Myocardial bridging is a condition in which an epicardial coronary artery (most frequently LAD) tunnels through the myocardium for a segment of variable length before re-entering the epicardial fat.⁶³ Clinical presentation is variable, including completely asymptomatic cases, as well as patients with chest pain, dyspnoea, or syncope⁶⁴ (Figure 6). It can occasionally cause effort-induced ischaemia due to coronary artery spasm and tachycardia and early atherosclerosis can be found in regions proximal to myocardial bridging, due to the high shear stress generated in these coronary segments.⁶⁵ The diagnostic pathway for this condition is based on the assessment of the abnormal anatomical features, primarily by cCTA, invasive coronary angiography with FFR, and intravascular ultrasound (IVUS).⁴⁹ Cardiac CTA offers direct non-invasive visualization of the anatomical relationship between myocardial bridging and the myocardium, identifying muscle fibres that overlie the tunnelled vessel. This non-invasive technique also makes it possible to characterize this anomaly in detail, measuring its length and depth and distinguishing superficial bridges, named ‘partial bridging’, in which the coronary artery lies in contact with the ventricular myocardium, and deep bridges, i.e. ‘complete bridging’, where the coronary artery is completely surrounded by the myocardium.^49,66 Invasive coronary angiography provides indirect angiographic signs of any myocardial bridging, known as the ‘milking effect’; it is defined as coronary diameter narrowing limited to a restricted segment with contrast agent extraction that cannot be explained by normal coronary flow, and the ‘step down–step up’ phenomenon, defined by a local change in vessel direction towards the ventricle.^67–69 However, invasive coronary angiography has lower sensitivity than cCTA for detecting myocardial bridging.⁶⁷ Indeed, the difference in the depiction rate of myocardial bridging between conventional coronary angiography and cCTA is significantly related to length, depth, and degree of systolic compression.⁶⁷ Beyond these limitations, FFR and instantaneous wave-free ratio can be measured during coronary catheterization IVUS. While IVUS provides indirect visualization of muscle fibres overlying the tunnelled segment as a ‘half-moon’ sign, an echolucency immediately adjacent to the vessel lumen, visible throughout the cardiac cycle,⁷⁰ FFR and instantaneous wave-free ratio indicate the functional significance of myocardial bridges, the latter being more consistent with patients’ symptoms and non-invasive test results than FFR.⁷¹

In terms of PPE, no clear morphological features have been highlighted as formal contraindications for competitive activity. However, Italian national recommendations suggest the importance of combining significant morphological details (i.e. length >10 mm and depth ≥3 mm) and diagnostic evidence of inducible ischaemia and/or symptoms (such as effort chest pain, dyspnoea, and syncope) during exercise-based stress to assess whether the competitive activity should be restricted. According to ESC Sports Cardiology Guidelines, competitive and leisure-time sports can be considered in the case of asymptomatic individuals with myocardial bridging and without inducible ischaemia or ventricular arrhythmia during maximal exercise testing (Class IIa).²¹

Future perspectives

Cardiovascular imaging has dramatically changed our management of athletes. The comprehensive cardiac assessment allowed by echocardiography and CMR has been further enhanced by computed tomography. Its unmatched capacity for a detailed morphological description of cardiac structures, especially the epicardial coronary arteries, coupled with the increasing availability of latest-generation scanners that drastically reduce radiation exposure (from >7 to <1 mSv with optimized acquisition parameters and protocols), is certain to lead to widespread use of this technique in sports cardiology.

The main criticism of cCTA assessment is its purely morphological nature: once anatomical abnormalities such as abnormal coronary origin, course, or myocardial bridging have been detected, their functional impact will in most cases determine subsequent clinical management. In these specific clinical contexts, a non-invasive multimodality imaging approach characterized by a combination of anatomical assessment with cCTA and functional assessment performed during physical exercise (i.e. exercise echocardiography) is probably the best option. However, recently developed CT-derived FFR analysis has been performed in cases of coronary origin and course abnormalities⁷² and myocardial bridging,⁷³ showing that this non-invasive functional CT analysis, along with specific morphological features, has a promising role in selecting subjects with increased risk of functional abnormalities.

Concerning the detection of CAD in master athletes, an increase in referrals for non-invasive coronary anatomy assessment can be expected, and solid data regarding the application of advanced tools in this specific setting are already available: on one hand, refined prognostication can be suggested with detailed plaque description and recognition of high-risk plaque features;⁷⁴ on the other, functional analysis such as CT-FFR and stress CT perfusion are excellent tools for increasing the diagnostic accuracy of cCTA in unfavourable settings, such as highly calcific atherosclerotic burden, thanks to their capacity to distinguish between ischaemic and non-ischaemic stenotic plaque.^75–77

Lastly, all imaging techniques are attempting to expand or enhance their fields of application by the implementation of deep learning analysis.⁷⁸ In view of the intrinsic nature of image dataset acquisition and reconstruction, computed tomography is an imaging technique very much in the spotlight of researchers and physicians.⁷⁹ The application of artificial intelligence to CT scans performed in athletes is an exciting prospect, especially when the goal is to refine PPE.

In conclusion, diagnostic assessment with cardiac imaging represents a milestone in the clinical management of competitive athletes. Of all the available techniques, computed tomography performed with the latest-generation scanners is the most promising tool for the near future. A sharp increase in the prescription of this diagnostic technique in PPE, as a complementary tool in suspected cases, is expected in the very near future.

Funding: None declared.

Data availability

Data availability statements is not applied given that original data were not presented on this manuscript.

References

Author notes