What is a suitable cardiovascular treatment plan for a 68-year-old weekend athlete with potential underlying cardiovascular risk factors, such as hypertension (high blood pressure) or hyperlipidemia (high cholesterol)?

Cardiovascular Treatment Plan for a 68-Year-Old Weekend Athlete

For a 68-year-old weekend athlete with cardiovascular risk factors, initiate comprehensive blood pressure and lipid screening immediately, implement lifestyle modifications as first-line therapy, and add pharmacological treatment with ACE inhibitors/ARBs or calcium channel blockers for hypertension and moderate-to-high intensity statins for lipid management based on cardiovascular risk stratification. 1, 2

Initial Assessment and Risk Stratification

Blood Pressure Evaluation:

• Measure blood pressure with appropriately sized cuff during preparticipation evaluation 1
• If initial readings show SBP >140 mmHg or DBP >90 mmHg, obtain comprehensive out-of-office measurements using ambulatory BP monitoring to exclude diagnostic errors 1
• For stage 2 hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg), obtain 12-lead ECG and echocardiogram to assess for left ventricular hypertrophy and distinguish pathologic remodeling from physiologic "athlete's heart" 1, 2

Lipid Assessment:

• Obtain fasting lipid panel to assess total cholesterol, LDL-C, HDL-C, and triglycerides 1
• Calculate 10-year cardiovascular disease risk to guide treatment intensity 1

Lifestyle Modifications (First-Line for All Risk Levels)

Dietary Interventions:

• Implement Mediterranean or DASH eating pattern emphasizing fruits, vegetables, and low-fat dairy products 1, 3
• Reduce saturated fat, trans fat, and sodium intake 1
• Increase dietary n-3 fatty acids, viscous fiber, and plant stanol/sterol intake 1
• Limit sugar-sweetened beverages 1

Physical Activity and Weight Management:

• Continue regular exercise participation, which provides blood pressure reduction benefits 1
• Maintain healthy body weight (BMI in normal range) 1, 4
• Increase physical activity levels if currently suboptimal 1

Alcohol and Tobacco:

• Limit alcohol to ≤2 standard drinks per day (maximum 14/week for men, 9/week for women) 1, 4
• Complete tobacco cessation with supportive care and referral to cessation programs 1

Pharmacological Management for Hypertension

Treatment Thresholds and Targets:

• For prehypertension (SBP 120-129 mmHg and DBP <80 mmHg): lifestyle modifications only, no sport restrictions 1
• For stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg): initiate antihypertensive medication if hypertension persists despite lifestyle modification 1
• For stage 2 hypertension (SBP ≥140 mmHg or DBP ≥90 mmHg): initiate pharmacological treatment promptly 1
• Target systolic BP of 120-129 mmHg if well tolerated, or "as low as reasonably achievable" if poorly tolerated 1

First-Line Medication Selection for Athletes:

• Preferred agents: Calcium channel blockers or ACE inhibitors/ARBs as first-line treatment 2
• These agents do not impair exercise performance in endurance athletes and are not on prohibited substance lists for most competitive sports 2
• Avoid beta-blockers as first-line unless specific indications exist (post-MI, heart failure, angina) 1

Combination Therapy:

• If monotherapy inadequate, combine calcium channel blocker with ACE inhibitor or ARB 2
• Use fixed-dose single-pill combinations when possible to improve adherence 1
• Never combine ACE inhibitor with ARB due to increased adverse events (hyperkalemia, syncope, acute kidney injury) without added benefit 1
• For three-drug therapy, add thiazide/thiazide-like diuretic to RAS blocker and calcium channel blocker 1

Critical Considerations:

• Cross-reference prescribed medications against sport-specific prohibited substance lists before prescribing 1, 2
• Obtain therapeutic use exemption if banned substance is medically necessary 1
• Monitor BP every 2-4 months once treatment initiated 1

Pharmacological Management for Hyperlipidemia

Statin Therapy Initiation:

• For ages 40-75 with diabetes or multiple ASCVD risk factors: initiate high-intensity statin therapy to reduce LDL-C by ≥50% and target LDL-C <70 mg/dL 1
• For ages >75 already on statin: continue treatment if well tolerated 1
• For ages >75 not on statin: consider moderate-intensity statin after discussing benefits and risks 1

Intensification Strategy:

• If LDL-C remains ≥70 mg/dL on maximum tolerated statin, add ezetimibe or PCSK9 inhibitor 1
• For statin-intolerant patients, use bempedoic acid as alternative cholesterol-lowering agent 1

Monitoring:

• Reassess lipid panel after initiating or adjusting therapy to ensure target achievement 1

Sport Participation Guidelines

Hypertension-Specific Restrictions:

• Stage 1 hypertension without target-organ damage: no sport restrictions 1
• Stage 2 hypertension: restrict from high static sports (weight lifting, wrestling) until BP controlled 1
• Athletes with LVH beyond physiologic athlete's heart: limit participation until BP normalized with therapy 1

Age-Specific Considerations:

• Older athletes (>60 years) with coronary artery disease, even with low-risk profiles, require more cautious advice and may need restrictions from extreme power and endurance disciplines 1
• Higher risk of sudden cardiac death during endurance events in men >60 years necessitates careful risk-benefit discussion 1

Ongoing Monitoring

Follow-Up Schedule:

• BP monitoring every 2-4 months during training season 1
• Monthly BP checks until target achieved, then every 3-5 months once controlled 2
• Annual lipid panel reassessment 1
• Periodic echocardiography if sustained hypertension to monitor for pathologic LVH 1

Red Flags Requiring Immediate Restriction:

• Hypertensive emergency (SBP >180 mmHg or DBP >120 mmHg with end-organ damage): no sport participation until adequate control achieved 1
• New cardiac symptoms (chest pain, syncope, dyspnea) during exercise: immediate comprehensive evaluation before return to sport 1