Coronary atherosclerosis in athletes: emerging concepts and preventive strategies
Open accessAbstract
There should be no assumption that an athlete is immune to coronary artery disease (CAD), even when traditional cardiovascular (CV) risk factors appear well-managed. Excelling in certain aspects of health does not equate to total CV protection. Recent data from cardiac imaging studies have raised the possibility that long-term, high-volume, high-intensity endurance exercise is associated with coronary atherosclerosis. Whilst the risk of CV events has not been shown to rise with athletic activity, the potential for CAD should not be overlooked as it is the leading cause of sudden cardiac death in athletes >35 years of age (i.e. ‘Masters athletes’). Evaluating both traditional and non-traditional risk factors for CAD is the most important part of pre-participation evaluation in Masters athletes. When managing athletes at risk of CAD it is important to adopt a shared decision-making approach regarding lifestyle adaptation and lipid-lowering treatments. In the great majority of athletes, after excluding the presence of symptoms and inducible ischaemia, this advice should include encouragement to continue exercising as available data indicate that higher levels of fitness are associated with a markedly attenuated incidence of coronary events regardless of the severity of coronary disease. Future research is needed to establish the relationship between clinically relevant CAD outcomes and coronary artery calcification in Masters Athletes, the role of sex, as well as exploration of the mechanisms underpinning these unexpected CV adaptations.
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Previous studies examining the link between training characteristics and CAD have yielded conflicting results, probably resulting from differences in training load definitions and measurement approaches.
“Previous studies examining the link between training characteristics and CAD have yielded conflicting results, probably resulting from differences in TL definitions and measurement approaches.12–14”
From Wearable-Derived Training Load and Coronary Atherosclerosis in Middle-Aged and Older Athletes and Physically Active Controls: A New Perspective From the Master@Heart Study (2026) · cites this paper as [12]
In “Coronary atherosclerosis in athletes—what is the evidence?” (page unavailable), the paper reports differing associations of exercise volume, duration, and intensity with coronary calcification and says more research is needed before drawing conclusions about training characteristics. It does not attribute those differences to inconsistent training-load definitions or measurement approaches. (LLM, conf=0.84)
Experimental — accuracy not yet measuredParticipant characteristics likely explain the linear associations between training load and CAD characteristics in this study population, as association across the full activity spectrum is hypothesized to be J-shaped.
“These participant characteristics likely explain the linear associations between TL and CAD characteristics in our study population, as association across the full activity spectrum is hypothesized to be J-shaped.12”
From Wearable-Derived Training Load and Coronary Atherosclerosis in Middle-Aged and Older Athletes and Physically Active Controls: A New Perspective From the Master@Heart Study (2026) · cites this paper as [12]
In “Coronary atherosclerosis in athletes—what is the evidence?” (page unavailable), the review hypothesizes a nonlinear relationship between endurance-exercise dose and the imaging-detected prevalence of coronary atherosclerosis. It calls that relationship reverse J-shaped, not J-shaped, and does not establish a relationship across the full activity spectrum. The proposed explanation for the citing study’s linear findings is the citing authors’ own interpretation. (LLM, conf=0.84)
Experimental — accuracy not yet measuredAthletes often consume higher total caloric and fat intake to meet training demands.
“In addition, athletes often consume higher total caloric and fat intake to meet training demands.12”
From Wearable-Derived Training Load and Coronary Atherosclerosis in Middle-Aged and Older Athletes and Physically Active Controls: A New Perspective From the Master@Heart Study (2026) · cites this paper as [12]
The “Potential aetiologies and modifying factors” section reports that master athletes have higher energy intake and higher absolute fat intake than the general population. It does not establish that this applies to athletes generally or say that the higher intake is to meet training demands. (LLM, conf=0.84)
Experimental — accuracy not yet measuredRepeated high-intensity exercise may alter hemodynamics by increasing shear stress, particularly in proximal coronary segments, potentially promoting focal atherosclerosis.
“First, repeated high-intensity exercise may alter hemodynamics by increasing shear stress, particularly in proximal coronary segments, potentially promoting focal atherosclerosis.12,29,30”
From Wearable-Derived Training Load and Coronary Atherosclerosis in Middle-Aged and Older Athletes and Physically Active Controls: A New Perspective From the Master@Heart Study (2026) · cites this paper as [12]
The Potential aetiologies and modifying factors section says high-intensity exercise may disrupt coronary flow, increase wall shear stress, and contribute to plaque formation. It does not say this mechanism particularly affects proximal coronary segments or produces focal atherosclerosis. The Introduction—case illustration describes one proximal lesion, but does not link its location to shear stress. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe analysis supports a reversed J-shaped association between exercise dose and CAD, with moderate physical activity offering cardiovascular protection and excessive endurance training possibly increasing atherosclerotic burden.
“Our analysis supports the hypothesis of a reversed J-shaped association between exercise dose and CAD as moderate physical activity offers cardiovascular protection, whereas excessive endurance training may increase atherosclerotic burden.6,7,9,12”
Male masters endurance athletes with seemingly low cardiovascular disease risk have shown an increased prevalence of high coronary artery calcium scores and a greater number of coronary plaques compared with relatively sedentary counterparts of similar age.
“However, male masters endurance athletes with seemingly low cardiovascular disease risk have shown an increased prevalence of high coronary artery calcium (CAC) scores and a greater number of coronary plaques compared with relatively sedentary counterparts of similar age.2–5”
From Resting and exercise-induced occult hypertension and coronary atherosclerosis in male masters endurance athletes (2026) · cites this paper as [5]
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Stepping up physical activity and fitness is needed for longevity
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- Authors
- Claessen, G., Eijsvogels, T. M. H., Albert, C. M., Baggish, A. L., Levine, B. D., Marijon, E., Michos, E. D., & La Gerche, A.
- Affiliations
- Jessa Hospital (BE)
- Radboud University Medical Center (NL)
- Cedars-Sinai Medical Center (US)
- Centre Hospitalier Universitaire Vaudois (CH)
- Texas Health Dallas (US)
- Paris Cardiovascular Research Center, Université Paris Cité, Inserm U970 , Paris ,
- Johns Hopkins University (US)
- Heart, Exercise and Research Trials (HEART) Lab, St. Vincent’s Institute of Medical Research , Melbourne ,
- Corresponding author
- Claessen, Guido
- ORCID
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2025-01-10
- Volume
- 46
- Issue
- 10
- Pages
- 890-903
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- PMC
- PMC11887545
- OpenAlex
- W4406243964
- Cited by
- 43
- References
- 102
- Citations by year
- 2026: 27 · 2025: 16
- FWCI
- 3.41
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- European Heart Journal (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- SERVAL (Université de Lausanne) (publishedVersion, cc-by)
- Document Server@UHasselt (UHasselt) (submittedVersion, cc-by)
- IRIS (submittedVersion, cc-by)
- Lirias (KU Leuven) (submittedVersion, cc-by)
- Radboud Repository (Radboud University) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Keywords
- coronary artery disease, endurance athletes, masters athletes, sudden cardiac death, cardiovascular risk factors, shared decision-making, lipid-lowering therapy, coronary artery calcification, sex differences
- MeSH terms
- Heart Disease Risk Factors, Adult, Coronary Artery Disease, Female, Humans, Male, Risk Factors, Exercise, Death, Sudden, Cardiac, Athletes
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