High-Volume Physical Activity and Clinical Coronary Artery Disease Outcomes: Findings From the Cooper Center Longitudinal Study
Abstract
Background High-volume physical activity (PA) is associated with a higher prevalence of subclinical coronary artery disease (CAD). However, the clinical significance of subclinical CAD among high-volume exercisers remains incompletely understood, and the dose-response relationship between high-volume PA and clinical CAD events remains uncertain. Methods Individual participant data from the Cooper Center Longitudinal Study (1987-2018) were linked to Medicare claims files. PA volume was determined by self-report and categorized as Results We included 26 724 participants (54 years of age; 28% women). Mean exercise volume was 1130 MET-minutes per week, with 1997 (7.5%) reporting ≥3000 MET-minutes per week. After a mean follow-up of 20.5 years, we observed 811 acute myocardial infarction events, 1636 composite CAD events, and 2857 deaths without CAD. Compared with individuals exercising 3000 MET-minutes per week) and risk for acute myocardial infarction (HR, 0.95 [95% CI, 0.72-1.25]). In contrast, the lowest risk for death was observed among the high-volume PA group (HR, 0.71 [95% CI, 0.60-0.83]). CAC (on log scale) was associated with a higher risk for composite CAD across all PA categories, including among the high-volume PA subgroup (HR, 1.29 [95% CI, 1.16-1.44]; P P interaction = 0.969). Conclusions Compared with low-volume PA, high-volume PA was associated with a lower risk for all-cause mortality but a similar risk for clinical CAD. CAC was associated with an increased risk…
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Emerging evidence supports the clinical relevance of CAC in athletes.
“Emerging evidence supports the clinical relevance of CAC in athletes.25,26”
Berry et al reported that higher CAC was associated with increased risk of acute coronary events irrespective of physical activity level, even among individuals reporting very high activity volumes (>3000 MET-min/week).
“Berry et al reported that higher CAC was associated with increased risk of acute coronary events irrespective of physical activity level, even among individuals reporting very high activity volumes (>3000 MET-min/week).26”
In that study, CAC>100 was associated with a fourfold higher risk of acute myocardial infarction compared with CAC 0, although high-volume physical activity remained associated with lower all-cause mortality.
“In that study, CAC>100 was associated with a fourfold higher risk of acute myocardial infarction compared with CAC 0, although high-volume physical activity remained associated with lower all-cause mortality.26”
Elevated coronary artery calcium, significant stenoses, and high-risk morphology plaques are strongly associated with increased risk for major adverse coronary events.
“Elevated CAC, significant stenoses, and high-risk morphology plaques are strongly associated with increased risk for major adverse coronary events.6”
From Resting and exercise-induced occult hypertension and coronary atherosclerosis in male masters endurance athletes (2026) · cites this paper as [6]
Large data from other studies have reported a lack of association between reported physical activity, CAC, and adverse coronary events in exercising females, including endurance athletes.
“Large data from other studies have also reported a lack of association between reported physical activity, CAC, and adverse coronary events in exercising females, including endurance athletes.6 35”
From Resting and exercise-induced occult hypertension and coronary atherosclerosis in male masters endurance athletes (2026) · cites this paper as [6]
Cites
World Health Organization 2020 guidelines on physical activity and sedentary behaviour
Bull, F. C., Al-Ansari, S. S., Biddle, S., Borodulin, K., Buman, M. P., Cardon, G., Carty, C., Chaput, J.-P., Chastin, S., Chou, R., et al. (2020) · British Journal of Sports Medicine · doi:10.1136/bjsports-2020-102955 · Cited by 11,657 · see citing works
The Physical Activity Guidelines for Americans
Piercy, K. L., Troiano, R. P., Ballard, R. M., Carlson, S. A., Fulton, J. E., Galuska, D. A., George, S. M., & Olson, R. D. (2018) · JAMA · doi:10.1001/jama.2018.14854 · Cited by 9,755 · see citing works
Mittleman, M. A., Maclure, M., Tofler, G. H., Sherwood, J. B., Goldberg, R. J., & Muller, J. E. (1993) · New England Journal of Medicine · doi:10.1056/nejm199312023292301 · Cited by 1,431 · see citing works
Physical Activity and Reduced Risk of Cardiovascular Events: Potential Mediating Mechanisms
Mora, S., Cook, N., Buring, J. E., Ridker, P. M., & Lee, I.-M. (2007) · Circulation · doi:10.1161/circulationaha.107.729939 · Cited by 1,000 · see citing works
Exercise Type and Intensity in Relation to Coronary Heart Disease in Men
Tanasescu, M. (2002) · JAMA · doi:10.1001/jama.288.16.1994 · Cited by 928 · see citing works
Franklin, B. A., Thompson, P. D., Al-Zaiti, S. S., Albert, C. M., Hivert, M.-F., Levine, B. D., Lobelo, F., Madan, K., Sharrief, A. Z., Eijsvogels, T. M. H., et al. (2020) · Circulation · doi:10.1161/cir.0000000000000749 · Cited by 410 · see citing works
Self-citationRelationship between lifelong exercise volume and coronary atherosclerosis in athletes.
Aengevaeren, V. L., Mosterd, A., Braber, T. L., Prakken, N. H. J., Doevendans, P. A., Grobbee, D. E., Thompson, P. D., Eijsvogels, T. M. H., & Velthuis, B. K. (2017) · Circulation · doi:10.1161/circulationaha.117.027834 · Cited by 309 · see citing works
Lee, D. H., Rezende, L. F. M., Joh, H.-K., Keum, N., Ferrari, G., Rey-Lopez, J. P., Rimm, E. B., Tabung, F. K., & Giovannucci, E. L. (2022) · Circulation · doi:10.1161/circulationaha.121.058162 · Cited by 288 · see citing works
Validity of myocardial infarction diagnoses in administrative databases: a systematic review.
McCormick, N., Lacaille, D., Bhole, V., & Avina-Zubieta, J. A. (2014) · PLoS ONE · doi:10.1371/journal.pone.0092286 · Cited by 262 · see citing works
Lifelong endurance exercise and its relation with coronary atherosclerosis
De Bosscher, R., Dausin, C., Claus, P., Bogaert, J., Dymarkowski, S., Goetschalckx, K., Ghekiere, O., Van De Heyning, C. M., Van Herck, P., Paelinck, B., et al. (2023) · European Heart Journal · doi:10.1093/eurheartj/ehad152 · Cited by 140 · see citing works
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Pauwels, R., Dausin, C., Ruiz-Carmona, S., De Bosscher, R., De Paepe, J., Bekhuis, Y., Delpire, B., Sinnaeve, P., Dymarkowski, S., Ghekiere, O., et al. (2026) · Circulation · doi:10.1161/circulationaha.125.077117 · Cited by 3 · see citing works
O’Driscoll, J., Parry-Williams, G., Moser, J., Vlahos, I., Obaid, D., Basu, J., Finocchiaro, G., Fyyaz, S., MacLachlan, H., Marwaha, S., et al. (2026) · British Journal of Sports Medicine · doi:10.1136/bjsports-2025-111347
- Authors
- Berry, J. D., Zabad, N., Kyrouac, D., Leonard, D., Barlow, C. E., Pavlovic, A., Shuval, K., Levine, B. D., & DeFina, L. F.
- Affiliations
- The University of Texas at Tyler (US)
- The University of Texas Southwestern Medical Center (US)
- Cooper Institute (US)
- Texas Health Dallas (US)
- ORCID
- Venue
- Circulation
- Published
- 2025-05-06
- Volume
- 151
- Issue
- 18
- Pages
- 1299-1308
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W4409621970
- Cited by
- 21
- References
- 10
- Citations by year
- 2026: 14 · 2025: 7
- FWCI
- 13.38
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Keywords
- coronary artery disease, subclinical coronary artery disease, coronary artery calcium, acute myocardial infarction, revascularization, all-cause mortality, dose-response relationship, exercise volume, Cooper Center Longitudinal Study, Medicare claims data
- MeSH terms
- Aged, Coronary Artery Disease, Female, Medicare, Humans, Longitudinal Studies, Male, Middle Aged, Risk Factors, United States, Exercise
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