In the middle of the journey of his life - the straight way was lost*

The case

The patient in this clinical case – like Dante Alighieri, the famous Italian poet – had to face certain troubles in the middle of the journey of his life. A 40-year-old male, Caucasian, amateur runner, approached our institute for a preparticipation screening for competitive sports activities. Asymptomatic at rest and during exercise. He had no family history for sudden cardiac death or heart diseases. He reported only hypercholesterolaemia (TC: 220 mg/dL) in familial dyslipidaemia and mild mitral valve prolapse, in regular echocardiographic follow-up. 

Clinical examination was normal, resting arterial blood pressure in optimal control (105/65 mmHg).

Resting ECG was normal for athletes, showing sinus rhythm, 59 bpm and an incomplete right bundle branch block (Figure1). 

Figure 1: resting ECG

The patient was at low risk according to the SCORE2 cardiovascular risk chart (SCORE2 < 2.5%)

He performed a maximal exercise test on a treadmill, RPE 18/20 reaching 90% of age-related maximum heart rate. Figures 2 and 3 show the athlete’s 12-lead ECG at peak exercise and at the second minute of recovery, respectively. The patient was always asymptomatic during exercise and in the recovery period; no major arrhythmias have been registered.

Figure 2: ECG at peak exercise 

Figure 3: ECG at the second minute of recovery

How would you describe these findings in your medical report, and would you prescribe further second-line investigations, based on which clinical suspicion?

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