I Want To Exercise (quick-read short version)
Do I Need A Cardiac Calcium Score CAT Scan First?
This is the extra-short version!
If you are a middle-aged person wondering whether you are at risk of heart attack when you start exercising, there are some resources for you.
(This is the TL/DR short version of a longer articlAssess your risk
The Framingham Risk Calculator is a good place to start. You’re going to need to know your total cholesterol, LDL cholesterol, HDL cholesterol, and blood pressure, and to know whether you are taking a “statin” cholesterol-lowering drug.
For most post-college sports, including recreational leagues, masters and senior events, and road races, there is no uniform requirement for a pre-participation check-up. Except in Italy, where it’s the law! So if you live outside of Italy, it’s going to be up to you do decide what to do about your risk.
New for 2025 we have up-to-date guidance from the American Heart Association and American College of Cardiology “Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities.”
A physical examination is still useful to detect things like high blood pressure and heart valve problems. The pre-participation cardiac evaluation now includes that an EKG test can be helpful but only if it is interpreted by a doctor who understands athletes’ hearts, and if there is access to follow-up testing needed to sort out the false positives.
Who should get a cardiac calcium score CAT scan?
If you are a masters athlete and otherwise low-risk for ASCVD (based on your check-up and Framingham Risk Calculator), you should probably not undergo advanced testing like a CAT scan. In this regard, “low-risk” means a risk score of less than 5% chance of ASCVD in the next 10 years.
But masters athletes with intermediate or high risk should
Learn about and adopt lifestyle changes (diet, alcohol, stop smoking) and follow guidelines about who should start preventive treatments like cholesterol-lowering drugs.
Learn about symptoms that might indicate heart disease so that they can get prompt attention if something comes up.
Consider further testing to assess their risk, including with a Calcium Score CAT scan, a maximal-effort exercise stress test (with or without imaging), or the fancier, more expensive CAT scan called coronary CT angiography. These tests might be reassuring; for example, a calcium score of zero would be considered by many doctors as a point against prescribing a cholesterol-lowering drug. But these tests might also suggest higher risk, and lead to a recommendation for more intensive treatment, or even a reconsideration of whether the risk of intense athletic competition is acceptable.
In general, the new approach does not say that a certain diagnosis disqualifies athletes from participation. “Shared decision-making” is the way things should now be done, discussing the risks among patient, doctor, and other stakeholders, to arrive at a joint decision. For specific cardiac conditions, the scientific statement gives information about the level of risk that doctors and patients can consider as they decide whether to continue participating in the sport despite their diagnosis.
Manage the risk of cardiac arrest by being prepared
Even a comprehensive program of pre-participation screening does not eliminate the risk of cardiac arrest during exercise. To make participation safer, the 2025 update specifies that programs can and should provide effective emergency action plans, including:
Prompt recognition of cardiac arrest
Personnel trained to provide effective CPR
Immediate availability and use of an AED (automatic external defibrillator)
A coordinated medical transport system to a defined facility
The emergency care programs should be developed, practiced, and used for all environments where competitive athletes train and compete.
When you have time, I hope you will read the full-length version of this article, which is much wittier!