APCU25CR11 Alive for one more game: a case report of repeat percutaneous coronary intervention (PCI) and safe return-to-sports

Introduction Exercise-associated syncope in athletes with ischemic heart disease complicates risk stratification and return-to-play decisions. We present a case of a master hockey player with previous coronary stenting who collapsed during play, required cardiopulmonary resuscitation (CPR) and repeat percutaneous coronary intervention (PCI), then completed structured cardiac rehabilitation to safely return- to-sport.Case Presentation A 60-year-old gentleman with two-vessel coronary stents placed 15 years earlier collapsed during a recreational hockey tournament in September 2023 after mild central chest discomfort. He was revived after ten minutes of CPR with one defibrillation shock.Results On arrival, electrocardiography (ECG) revealed T-wave inversions in leads III and aVF, and troponin-I level of 5,710ng/L. Transthoracic echocardiography showed left ventricular systolic dysfunction with ejection fraction (EF) of 45% and regional hypokinesis of the basal inferolateral, basal-to-mid inferoseptal, and basal-to-mid inferior segments. Coronary angiography identified in-stent restenosis in the mid–right coronary artery, which was successfully treated with PCI. Post-PCI, ECG showed new T-wave inversions in leads II, III, aVF, and V4–V6 with QTc prolongation, and troponin-I peaked at 10,145ng/L. In June 2024, an exercise stress test reached 13.4METs, upsloping ST-segment depression at 140bpm, and appropriate hemodynamic responses without symptoms. A six-week cardiac rehabilitation program was initiated with a progressive exercise regimen guided by heart rate. Weeks 1–2 targeted 120–140bpm, weeks 3–4 130–140bpm, and weeks 5–6 140–150bpm with post-exercise troponin monitoring. Resistance training (50–70% 1RM) included bicep curls, leg presses, and hamstring curls. Post-rehabilitation echocardiography showed normalization of regional wall motion and an LVEF of 61%, with persistent grade I diastolic dysfunction. CardioPulmonary Exercise Testing (CPET) demonstrated VO&noentity8322;max of 33.8ml·kg&noentity8315; 1·min&noentity8315;1, VE/VCO&noentity8322; of 41, VE/VCO&noentity8322; slope of 27.5, and an O&noentity8322; pulse of 15.3ml/beatDiscussion This case highlights the importance of structured, heart rate–guided exercise promotes myocardial adaptation and minimizes recurrent ischemia. Integrating CPET refines risk stratification and informs safe exercise prescriptions.Conclusion In master athletes with prior PCI need a tailored cardiac rehabilitation protocol and timely screening, not only to prevent sudden cardiac death in sports but also safely guiding in return-to-competitive sport. Annual follow-up is recommended to detect restenosis and preserve cardiovascular health.