Acute Coronary Syndrome in a Master's Athlete and No Modifiable Risk: Gaps in Return-to-Play Guidance.

backgroundAcute coronary syndrome (ACS) is the leading cause of sudden cardiac death in master's athletes. Current return-to-competition guidelines recommend cardiac rehabilitation and risk factor modification, but do not address athletes lacking modifiable risk factors or revascularization options. CASE SUMMARY: A 46-year-old male competitive runner developed ACS from plaque rupture following a marathon. Stenting was deferred due to malapposition risk with large-caliber coronaries. He completed cardiac rehabilitation and was cleared to return to competition at 6 months. WHY BEYOND THE GUIDELINES?: This patient had no modifiable risk factors and was not a candidate for revascularization, leaving his pre- and postevent cardiovascular risk unchanged despite meeting guideline criteria for return to competition. DISCUSSION: Conventional risk stratification tools, including risk calculators and coronary calcium scoring, are less accurate in master's athletes, creating a gap in counseling unrevascularized patients. TAKE-HOME MESSAGE: Master's athletes with ACS, no modifiable risk factors, and unrevascularized lesions require improved risk stratification tools and further research to guide return-to-competition counseling.