30,31 There are

also no data to suggest that exposure to altitudes up to 2,500 m increases the incidence of SCD26,32 or myocardial infarction (MI) in patients with CAD.2,5,30,33 However, a theoretical potential for increased risk exists in that both myocardial oxygen delivery and requirements are altered with exposure to high altitude. CAD is associated with an increased risk of SCD during skiing and hiking in the mountains.26,34 Acute hypoxia,35 physical activity, dehydration, and cold cause sympathetic activation at altitude,36 the results of which include vasoconstriction and an increase in heart rate, blood pressure, and cardiac output.5,36 This increase in cardiac workload and oxygen demands is most notable in the first 3 days of altitude CDK activation exposure.2,36–40 People with CAD have significantly reduced capacity to compensate for the increased demands on the heart, even at moderate altitude.40 Diseased arteries have impaired endothelial

vasomotor control, and thus alkalosis, cold, and unopposed sympathetic activity may cause constriction of the coronary arteries and reduced myocardial perfusion.36 Levine and colleagues noted a 5% decrease in the angina threshold for people with CAD in the preacclimatization period at 2,500 m.38 Wyss and colleagues demonstrated an 18% decline in exercise-induced coronary flow reserve in patients with stable obstructive CAD at 2,500 m.40 Additionally, at altitude, myocardial oxygenation in areas supplied by stenotic arteries is significantly reduced Etofibrate relative to areas supplied by healthy vessels.40 Patients with CAD may be at significant risk of life-threatening ventricular buy BMS-907351 arrhythmias at altitude due to the combined effects of pulmonary hypertension and myocardial ischemia.41,42 Patients with exertional angina at their resident altitude will likely

experience a worsening of their symptoms at higher altitude. Thus, travel to high altitude is not recommended and exercise at altitude is generally contraindicated in this cohort.5,31,43 However, Morgan and colleagues proposed that patients are safe to exert themselves at altitudes up to a target heart rate which is 70% to 80% of their low altitude ischemic endpoint.44 Patients with well-controlled CAD who participate in unrestricted physical activity at sea level are probably safe to travel up to 2,500 m.31,36,38,40 However, it is recommended that physical exertion should be avoided for the duration of a 3- to 5-day acclimatization period.26,27,30 Adequate nutrition and hydration should be maintained at all times to minimize the risk of adverse events.26 Wyss and colleagues40 recommend further caution, stating that people with CAD should avoid physical exertion even at moderate altitudes. Travel to high altitude is contraindicated for 6 months following an MI. After 6 months, a normal exercise stress test should be a prerequisite to travel.