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Cited by 3Cardiovascular Effects of ExerciseCardiovascular and exercise physiologyCardiac Imaging and Diagnostics

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

Open access
Pauwels, Rik, Dausin, Christophe, Ruiz-Carmona, Sergio, De Bosscher, Ruben, De Paepe, Jarne, Bekhuis, Youri, Delpire, Boris, Sinnaeve, Peter +37 more·2026·Circulation
DOI 10.1161/circulationaha.125.077117PMC PMC13056411
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Abstract

BACKGROUND: Middle-aged and older endurance athletes have increased prevalence of coronary artery disease (CAD) on coronary computed tomography angiography compared with healthy controls, despite similarly low cardiovascular risk. Previous studies relied on self-reported data to quantify training load (TL), which poorly correlates with objective wearable-derived TL and may bias outcomes. The effect of objective TL on CAD risk remains unknown. METHODS: In this observational, cross-sectional analysis of the Master@Heart study, 222 men (median age, 54 [49–59] years) were included: 77 lifelong athletes, 98 late-onset athletes, and 47 controls. TL was assessed using objective wearable-derived training duration and intensity (12 consecutive months), as well as self-reported training measures. Coronary computed tomography angiography–derived CAD prevalence was compared across TL quartiles (Q) using a global unadjusted chi-square test and logistic regression, adjusted for cardiovascular risk factors and years of endurance exercise, to estimate odds ratios between Q4 and Q1. In addition, adjusted logistic regression models were fitted with continuous TL, using smoothing splines to capture potential nonlinear associations. RESULTS: Across quartiles of objective Edwards training impulse (training duration × heart rate–weighted intensity), unadjusted global differences were observed for ≥1 plaque ( P <0.001), coronary artery calcification (CAC)>0 ( P =0.002), and CAC>100 ( P =0.012). Q4 participants had significantly higher adjusted odds of ≥1 plaque (odds ratio, 5.85; 95% CI, 2.33–14.71), CAC>0 (odds ratio, 5.03; 95% CI, 2.04–12.35), and CAC>100 (odds ratio, 3.50; 95% CI, 1.22–10.00) versus Q1. Similar associations were found for objective training duration, whereas no clear associations were observed for relative time spent in high-intensity zones. In continuous analyses, Edwards training impulse and objective training duration showed significant positive associations with ≥1 plaque and CAC>100 ( P <0.05), whereas self-reported training duration was only significantly associated with CAC>100 ( P <0.05). Metabolic equivalent of task-minutes per week based on self-reported TL was not associated with CAD ( P >0.05). CONCLUSIONS: High training duration (hours/week), particularly when combined with cumulative high-intensity TL (Edwards training impulse), was independently associated with increased prevalence of subclinical CAD in middle-aged and older athletes and physically active controls. Exercise intensity alone, in the absence of high duration, was not clearly linked to CAD. These findings underscore the potential of objectively measured TL for understanding associations with subclinical CAD in endurance athletes. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03711539.

AI snapshot

Written from the paper’s full text.

TL;DR

In a cross-sectional Master@Heart analysis of 222 middle-aged/older men, objectively measured high training load—especially high training duration combined with cumulative high-intensity load (Edwards training impulse, eTRIMP)—was independently associated with more subclinical coronary atherosclerosis on CCTA. Exercise intensity alone, without high duration, was not clearly linked to CAD.

Key findings

  • Across eTRIMP quartiles, Q4 vs Q1 had higher adjusted odds of ≥1 plaque (74.5% vs 36.4%; OR, 5.85; 95% CI, 2.33–14.71), CAC>0 (69.1% vs 32.7%; OR, 5.03; 95% CI, 2.04–12.35), and CAC>100 (38.2% vs 14.5%; OR, 3.50; 95% CI, 1.22–10.00).
  • For objective training duration, Q4 (9.2–26.5 hours/week) vs Q1 (0.5–3.3 hours/week) had higher adjusted odds of ≥1 plaque (70.9% vs 40.0%; OR, 4.42; 95% CI, 1.63–11.90), CAC>0 (65.5% vs 36.4%; OR, 4.13; 95% CI, 1.52–11.11), and CAC>100 (41.8% vs 16.4%; OR, 4.46; 95% CI, 1.36–14.71).
  • Continuous analyses showed eTRIMP positively associated with ≥1 plaque (OR, 1.14 per 100 AU; 95% CI, 1.06–1.21), CAC>0 (OR, 1.12; 95% CI, 1.05–1.19), and CAC>100 (OR, 1.11; 95% CI, 1.03–1.20); objective training duration showed similar positive associations.
  • Self-reported MET-min/week was not associated with CAD (P>0.05), and self-reported training duration was only significantly associated with CAC>100 (OR, 1.07; 95% CI, 1.00–1.15; P=0.047); relative time in high-intensity zones showed no consistent dose-response.

Methods

  • Observational, cross-sectional secondary analysis of the Master@Heart study including 222 men (median age, 54 [49–59] years): 77 lifelong athletes, 98 late-onset athletes, and 47 physically active controls.
  • Training load was assessed from wearable device data over 12 consecutive months via TrainingPeaks and custom software, including objective training duration, heart-rate zones, and eTRIMP; self-reported training duration and MET-min/week were also collected.
  • CCTA-derived CAD characteristics were compared across TL quartiles using unadjusted chi-square tests and adjusted logistic regression (Q4 vs Q1), plus continuous logistic models with penalized smoothing splines; adjustments included traditional cardiovascular risk factors and years of endurance exercise, with duration models additionally adjusted for high-intensity time and intensity models adjusted for duration.

Limitations

  • Stated: the cohort was exclusively White men age 45–70 years, limiting generalizability to women and other ethnicities; 12 months of training data may not fully reflect lifelong exposure; 86 participants had TL collected after CCTA, though a timing covariate was not significantly associated with CAD; occasional sessions without a wearable may cause minor nondifferential underestimation of TL.
  • Stated: the study population included only endurance athletes and physically active low-risk controls, so sedentary and higher-risk individuals at the low-activity end of the hypothesized J-shaped curve were not represented.
  • Evident from the text: the cross-sectional design cannot establish causality, and the reliance on a selected low-risk active cohort limits inference about thresholds or long-term clinical outcomes.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1161/circulationaha.125.077117

Cites

36 of 37 references verified0 citation errors · 1 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

27 of 41 cited sources checked · 11 supported · 2 flagged · accuracy not yet measured

  • Interpretationcitation

    Repeated 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”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [12] Claessen G Eijsvogels TMH Albert CM Baggish AL Levine BD Marijon E Michos ED La Gerche A. Coronary atherosclerosis in athletes: emerging concepts and preventive strategies. Eur Heart J. 2025; 46: 890– 903. doi: 10.1093/eurheartj/ehae927 39791533 PMC11887545 source

      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 measured
    • cites [29] Wang YX Bin Liu H Li PS Yuan WX Liu B Liu ST Qin KR. ROS and NO dynamics in endothelial cells exposed to exercise-induced wall shear stress. Cell Mol Bioeng. 2018; 12: 107– 120. doi: 10.1007/S12195-018-00557-W 31719902 PMC6816775 source

      The Introduction and Discussion (pages unavailable) state that exercise increases the magnitude and frequency of wall shear stress, including under conditions modeled for high-intensity exercise. The paper does not establish that this occurs particularly in proximal coronary segments or that repeated high-intensity exercise promotes focal atherosclerosis; its experiments concern endothelial-cell ROS and NO responses in a flow chamber. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [30] Chiu JJ Chien S. Effects of disturbed flow on vascular endothelium: pathophysiological basis and clinical perspectives. Physiol Rev. 2011; 91: 327– 387. doi: 10.1152/physrev.00047.2009 21248169 PMC3844671 source

      Section VIII.A (page unavailable) agrees that exercise increases flow and shear stress, but says this may retard or reverse coronary artery disease—not promote it. Section V.B (page unavailable) reports lesions in low-shear regions and none in a high-shear region. The cited passages do not identify proximal coronary segments as a site of exercise-related focal atherosclerosis. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    Partially calcified and noncalcified plaques are more vulnerable to plaque rupture than calcified plaques.

    “This is clinically relevant because these plaque types are more vulnerable to plaque rupture than calcified plaques.10,11”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [10] Hou ZH Lu B Gao Y Jiang SL Wang Y Li W Budoff MJ. Prognostic value of coronary CT angiography and calcium score for major adverse cardiac events in outpatients. JACC Cardiovasc Imaging. 2012; 5: 990– 999. doi: 10.1016/j.jcmg.2012.06.006 23058065 source

      The Discussion reports higher three-year major adverse cardiac event rates for noncalcified and mixed plaques than for calcified plaques, and describes soft, lipid-filled plaques as vulnerable. The paper does not report a comparison of plaque-rupture rates for these plaque types, so the rupture-specific claim goes beyond its findings. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [11] Jinnouchi H Sato Y Sakamoto A Cornelissen A Mori M Kawakami R Gadhoke NV Kolodgie FD Virmani R Finn AV. Calcium deposition within coronary atherosclerotic lesion: implications for plaque stability. Atherosclerosis. 2020; 306: 85– 95. doi: 10.1016/j.atherosclerosis.2020.05.017 32654790 source
  • Premisecitation

    The Master@Heart study found a higher burden of less favorable plaque types, such as partially calcified and noncalcified plaques, in lifelong athletes.

    “The Master@Heart study confirmed this observation and, in contrast with earlier reports, also found a higher burden of less favorable plaque types, such as partially calcified and noncalcified plaques, in lifelong athletes.9”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] De Bosscher R Dausin C Claus P Bogaert J Dymarkowski S Goetschalckx K Ghekiere O Van De Heyning CM Van Herck P Paelinck B. Lifelong endurance exercise and its relation with coronary atherosclerosis. Eur Heart J. 2023; 44: 2388– 2399. doi: 10.1093/eurheartj/ehad152 36881712 PMC10327878 source
  • Premisecitation

    Middle-aged and older endurance athletes have increased prevalence of coronary artery disease on coronary computed tomography angiography compared with healthy controls, despite similarly low cardiovascular risk.

    “Middle-aged and older endurance athletes have increased prevalence of coronary artery disease (CAD) on coronary computed tomography angiography compared with healthy controls, despite similarly low cardiovascular risk.”
    • Also stated in: § What Are the Clinical Implications? · hedged
      “Paradoxically, emerging evidence suggests that middle-aged and older male endurance athletes, despite favorable cardiovascular risk profiles, may have a higher prevalence of coronary artery calcification (CAC) and plaques on coronary computed tomography angiography (CCTA) compared with less active peers.6–8”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [6] Aengevaeren VL Mosterd A Braber TL Prakken NHJ Doevendans PA Grobbee DE Thompson PD Eijsvogels TMH Velthuis BK. Relationship between lifelong exercise volume and coronary atherosclerosis in athletes. Circulation. 2017; 136: 138– 148. doi: 10.1161/CIRCULATIONAHA.117.027834 28450347 source

      The Abstract (p. 3) reports more CT-detected plaque in men with the highest versus lowest lifelong exercise volumes. But the Limitations (p. 19) explicitly state that the study had no general-population control group and could not compare athletes with non-athletes. It therefore does not establish the claimed comparison with healthy controls or similarly low cardiovascular risk across those groups. (LLM, conf=0.91)

      Experimental — accuracy not yet measured
    • cites [7] Merghani A Maestrini V Rosmini S Cox AT Dhutia H Bastiaenan R David S Yeo TJ Narain R Malhotra A. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017; 136: 126– 137. doi: 10.1161/CIRCULATIONAHA.116.026964 28465287 source
    • cites [8] Möhlenkamp S Lehmann N Breuckmann F Bröcker-Preuss M Nassenstein K Halle M Budde T Mann K Barkhausen J Heusch G; Marathon Study Investigators. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J. 2008; 29: 1903– 1910. doi: 10.1093/eurheartj/ehn163 18426850 source
  • Study design and conductcitation

    Twelve months of training data may not fully reflect lifelong exposure.

    “Although 12 months of training data offer a robust estimate of recent exercise behavior,15 they may not fully reflect lifelong exposure.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source
  • Classified as probably not a substantial claim. 20
  • May combine two claims. 33

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Maximal heart rate was defined as the highest heart rate value recorded during any training session, following a validated approach.

    “Maximal HR (HRmax) was defined as the highest HR value recorded during any training session, following a validated approach, as HRmax achieved during training sessions often exceeds values obtained during cardiopulmonary exercise testing.15”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source

      The Automatic Determination of MaxHR section says the paper estimated training MaxHR from the distribution of session maxima using a validated tangent method, rather than defining it as the highest value recorded in any one session. The Maximal Heart Rate results support the separate rationale that field estimates exceeded lab values. Page numbers were not available in our copy. (LLM, conf=0.87)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    Aengevaeren et al showed that high-volume exercise (>2000 MET-min/week) was associated with higher CAC and plaque prevalence.

    “Aengevaeren et al showed that high-volume exercise (>2000 MET-min/week) was associated with higher CAC and plaque prevalence,6”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [6] Aengevaeren VL Mosterd A Braber TL Prakken NHJ Doevendans PA Grobbee DE Thompson PD Eijsvogels TMH Velthuis BK. Relationship between lifelong exercise volume and coronary atherosclerosis in athletes. Circulation. 2017; 136: 138– 148. doi: 10.1161/CIRCULATIONAHA.117.027834 28450347 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Aengevaeren et al later reported a relationship between high-intensity exercise, rather than exercise volume, with CAD progression.

    “and later reported a relationship between high-intensity exercise, rather than exercise volume, with CAD progression.14”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [14] Aengevaeren VL Mosterd A Bakker EA Braber TL Nathoe HM Sharma S Thompson PD Velthuis BK Eijsvogels TMH. Exercise volume versus intensity and the progression of coronary atherosclerosis in middle-aged and older athletes: findings from the MARC-2 study. Circulation. 2023; 147: 993– 1003. doi: 10.1161/CIRCULATIONAHA.122.061173 36597865 source

  • May combine two claims.

    Interpretationreasoning

    Participant 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”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [12] Claessen G Eijsvogels TMH Albert CM Baggish AL Levine BD Marijon E Michos ED La Gerche A. Coronary atherosclerosis in athletes: emerging concepts and preventive strategies. Eur Heart J. 2025; 46: 890– 903. doi: 10.1093/eurheartj/ehae927 39791533 PMC11887545 source

      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 measured

  • May combine two claims.

    Study design and conductcitation

    The study used a novel semiautomated software platform capable of processing and aggregating wearable data over 12 months, enabling comprehensive and unbiased assessment of exercise exposure.

    “In the present study, we overcome this limitation by applying a novel, semiautomated software platform capable of processing and aggregating wearable data over a 12-month time period.15 This enables a comprehensive and unbiased assessment of exercise exposure, incorporating training duration and intensity.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source

  • May combine two claims.

    Premisecitation

    Previous evidence on the role of training load in coronary artery disease is exclusively based on self-reported training load, which is prone to recall bias and shows weak correlation with objectively measured data.

    “Previous studies relied on self-reported data to quantify training load (TL), which poorly correlates with objective wearable-derived TL and may bias outcomes.”
    • Also stated in: § What Are the Clinical Implications? · plain
      “However, this evidence is exclusively based on self-reported TL, which is prone to recall bias and showed weak correlation with objectively measured data.15”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source

      The Abstract says sports-cardiology studies have relied on questionnaires and that recall and reporting errors limit their reliability. The Questionnaires section reports no significant correlation between self-reported and heart-rate-recorded training sessions or hours. The paper does not establish the narrower claim that evidence specifically on coronary artery disease is exclusively based on self-reported training load. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    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”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [12] Claessen G Eijsvogels TMH Albert CM Baggish AL Levine BD Marijon E Michos ED La Gerche A. Coronary atherosclerosis in athletes: emerging concepts and preventive strategies. Eur Heart J. 2025; 46: 890– 903. doi: 10.1093/eurheartj/ehae927 39791533 PMC11887545 source

      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 measured
    • cites [13] Pavlovic A DeFina LF Leonard D Radford NB Farrell SW Barlow CE Shuval K Berry JD Levine BD. Coronary artery calcification and high-volume physical activity: role of lower intensity vs. longer duration of exercise. Eur J Prev Cardiol. 2024; 31: 1526– 1534. doi: 10.1093/eurjpc/zwae150 38651686 source
    • cites [14] Aengevaeren VL Mosterd A Bakker EA Braber TL Nathoe HM Sharma S Thompson PD Velthuis BK Eijsvogels TMH. Exercise volume versus intensity and the progression of coronary atherosclerosis in middle-aged and older athletes: findings from the MARC-2 study. Circulation. 2023; 147: 993– 1003. doi: 10.1161/CIRCULATIONAHA.122.061173 36597865 source

      The Exercise Volume section (page unavailable) describes differing findings across studies: MARC-2 found no association with progression, while a Korean population study found greater CAC progression in a more active group. It also describes different activity categories and suggests that follow-up duration may matter, but it does not say that differences in training-load definitions and measurement approaches probably caused the conflicting results. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The study included the Edwards training impulse, a heart rate-based composite measure of internal training load that combines training duration and intensity.

    “We included the Edwards training impulse (eTRIMP), a heart rate (HR)–based composite measure of internal TL that combines training duration and intensity.15”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source

  • May combine two claims.

    Interpretationcitation

    The 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”
    Quote in the paperSubstantial claim3 of 4 sources checked
    • cites [6] Aengevaeren VL Mosterd A Braber TL Prakken NHJ Doevendans PA Grobbee DE Thompson PD Eijsvogels TMH Velthuis BK. Relationship between lifelong exercise volume and coronary atherosclerosis in athletes. Circulation. 2017; 136: 138– 148. doi: 10.1161/CIRCULATIONAHA.117.027834 28450347 source

      The Results (p. 13) and Figure 2 caption (p. 29) report more coronary calcification and plaque in the highest lifelong exercise-volume group than in the lowest, supporting the possibility of greater atherosclerotic burden with high exercise volumes. The Introduction (p. 6) notes lower cardiovascular-event risk with physical activity, but this study does not establish that moderate exercise protects against CAD or demonstrate a reversed J-shaped association. The Discussion (p. 14) also notes that plaques in the most active athletes had a more benign composition. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [7] Merghani A Maestrini V Rosmini S Cox AT Dhutia H Bastiaenan R David S Yeo TJ Narain R Malhotra A. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017; 136: 126– 137. doi: 10.1161/CIRCULATIONAHA.116.026964 28465287 source
    • cites [9] De Bosscher R Dausin C Claus P Bogaert J Dymarkowski S Goetschalckx K Ghekiere O Van De Heyning CM Van Herck P Paelinck B. Lifelong endurance exercise and its relation with coronary atherosclerosis. Eur Heart J. 2023; 44: 2388– 2399. doi: 10.1093/eurheartj/ehad152 36881712 PMC10327878 source
    • cites [12] Claessen G Eijsvogels TMH Albert CM Baggish AL Levine BD Marijon E Michos ED La Gerche A. Coronary atherosclerosis in athletes: emerging concepts and preventive strategies. Eur Heart J. 2025; 46: 890– 903. doi: 10.1093/eurheartj/ehae927 39791533 PMC11887545 source

  • May combine two claims.

    Premisecitation

    Previous studies have found no association between lifelong exercise and CAD in female athletes, supporting the focus on males in this analysis.

    “Furthermore, previous studies have found no association between lifelong exercise and CAD in female athletes, supporting our focus on males in this analysis.36”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [36] Papatheodorou E Aengevaeren VL Eijsvogels TMH Alfakih K Hughes RK Merghani A Kissel CK Fyyaz S Bakalakos A Wilson MG. Prevalence of coronary atherosclerosis in female masters endurance athletes. Circulation. 2024; 150: 1478– 1480. doi: 10.1161/CIRCULATIONAHA.124.069484 39466884 source

      In section S (page not supplied), the paper reports no significant difference between female Masters athletes and controls in overall coronary calcium or plaque prevalence. But it also reports lower prevalence of some calcium-score measures and mixed plaques in athletes, while years of exercise was associated with detectable calcium in univariate analysis. Thus, 'no association' is broader than the findings support. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Berge et al found an inverse association between higher fat intake and coronary plaque burden in athletes, likely reflecting the mitigating effects of adherence to a Mediterranean diet.

    “Berge et al found an inverse association between higher fat intake and coronary plaque burden in athletes, likely reflecting the mitigating effects of adherence to a Mediterranean diet,33”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [33] Berge K Janssen SLJE Velthuis BK Myhre PL Mosterd A Omland T Eijsvogels TMH Aengevaeren VL. Predictors of coronary atherosclerosis in middle-aged and older athletes: the MARC-2 study. Eur Heart J Cardiovasc Imaging. 2025; 26: 461– 470. doi: 10.1093/EHJCI/JEAE317 39657626 source

      The Results report an inverse association between fat percentage of energy intake and coronary artery calcification (CAC) in the athletes. The Discussion compares this finding with a Mediterranean-diet trial but explicitly says whether the same mechanisms operated in MARC-2 is unknown; the Limitations also state that plaque volume and composition were not measured. The proposed explanation involving Mediterranean-diet adherence and the broader claim about plaque burden therefore go beyond this study's findings. (LLM, conf=0.89)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Aengevaeren et al defined "very vigorous" exercise intensity as >9 METs, a threshold commonly exceeded by endurance athletes and insufficient to distinguish training extremes in this population.

    “However, they defined “very vigorous” exercise intensity as >9 METs, a threshold commonly exceeded by endurance athletes and insufficient to distinguish training extremes in this population.14,17”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [14] Aengevaeren VL Mosterd A Bakker EA Braber TL Nathoe HM Sharma S Thompson PD Velthuis BK Eijsvogels TMH. Exercise volume versus intensity and the progression of coronary atherosclerosis in middle-aged and older athletes: findings from the MARC-2 study. Circulation. 2023; 147: 993– 1003. doi: 10.1161/CIRCULATIONAHA.122.061173 36597865 source

      The methods passage (page unavailable) defines very vigorous exercise as ≥9 METs, not strictly >9 METs. The Results report a median of 34% of exercise volume at that intensity among participants, but the paper does not say the threshold is commonly exceeded by endurance athletes generally or that it is insufficient to distinguish training extremes. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [17] Ainsworth BE Haskell WL Herrmann SD Meckes N Bassett DR Tudor-Locke C Greer JL Vezina J Whitt-Glover MC Leon AS. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011; 43: 1575– 1581. doi: 10.1249/MSS.0b013e31821ece12 21681120 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Athletes 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”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [12] Claessen G Eijsvogels TMH Albert CM Baggish AL Levine BD Marijon E Michos ED La Gerche A. Coronary atherosclerosis in athletes: emerging concepts and preventive strategies. Eur Heart J. 2025; 46: 890– 903. doi: 10.1093/eurheartj/ehae927 39791533 PMC11887545 source

      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 measured

  • May combine two claims.

    Premisecitation

    Previous work in this cohort has shown that self-reported training duration correlates poorly with objective training duration, whereas wearable-derived eTRIMP closely matches gold standard physiological indices such as the Lucia TRIMP.

    “Previous work in this cohort has shown that self-reported training duration correlates poorly with objective training duration, whereas wearable-derived eTRIMP closely matches gold standard physiological indices such as the Lucia TRIMP (Training Impulse).15”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [15] Dausin C Ruiz-Carmona S De Bosscher R Janssens K Herbots L Heidbuchel H Hespel P Cornelissen V Willems R La Gerche A. Semiautomatic training load determination in endurance athletes. J Meas Phys Behav. 2023; 6: 193– 201. doi: 10.1123/jmpb.2023-0016 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Median weekly average Edwards training impulse across the entire cohort was 914 arbitrary units (interquartile range 478-1281).

    “Median weekly average eTRIMP across the entire cohort was 914 AU (478–1281; Table S1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Comparisons of the highest versus third quartile were directionally similar but mostly not significant, except for objective training duration, where coronary artery calcification >100 and partially calcified plaque remained significant.

    “Comparisons of Q4 versus Q3 were directionally similar but mostly not significant, except for objective training duration, where CAC>100 and partially calcified plaque remained significant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Across Edwards training impulse quartiles, there was a significant unadjusted global difference in prevalence of at least one plaque, proximal plaques, calcified plaques, noncalcified plaques, partially calcified plaques, coronary artery calcification >0, and coronary artery calcification >100, but not coronary artery calcification percentile ≥75.

    “Across eTRIMP quartiles, there was a significant, unadjusted global difference in the prevalence of ≥1 plaque (P<0.001), proximal plaques (P=0.016), calcified plaques (P=0.008), noncalcified plaques (P=0.047), partially calcified plaques (P=0.013), CAC>0 (P=0.002), and CAC>100 (P=0.012), whereas differences for CAC percentile ≥75 (P=0.178) did not reach statistical significance.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The highest intensity quartile showed elevated odds for selected CAD features compared with the lowest quartile, but no consistent dose-response pattern across intensity categories was observed.

    “Although the highest intensity quartile showed an elevated odds for selected CAD features compared with the lowest quartile, no consistent dose-response pattern across intensity categories was observed.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    No clear dose-response or significant differences were observed for relative time in high-intensity exercise comparing the highest quartile with the second and third quartiles.

    “In contrast, no clear dose-response or significant differences were observed for relative time in high-intensity exercise comparing Q4 with Q2 to Q3 (Table S9).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    When stratified by quartiles of objective training duration, global unadjusted P values indicated significant differences for at least one plaque, calcified plaques, partially calcified plaques, coronary artery calcification >0, and coronary artery calcification >100, and nonsignificant trends for other characteristics.

    “When stratified by quartiles of objective training duration, global unadjusted P values indicated significant differences for ≥1 plaque (P=0.008), calcified plaques (P=0.034), partially calcified plaques (P=0.005), CAC>0 (P=0.011), and CAC>100 (P=0.001), and nonsignificant trends for other characteristics.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Trends for noncalcified plaques and coronary artery calcification percentile ≥75 across Edwards training impulse quartiles were directionally similar but did not reach statistical significance.

    “Trends for noncalcified plaques and CAC percentile ≥75 were directionally similar but did not reach statistical significance (Table 2; Figure 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Sedentary individuals and those with traditional cardiovascular risk factors were not represented in the cohort.

    “Sedentary individuals and those with traditional cardiovascular risk factors, who typically populate the higher-risk, low-activity end of the curve, were not represented.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In our study, participants in the highest eTRIMP category showed a higher prevalence of partially calcified, noncalcified, and proximal plaques.

    “In our study, participants in the highest eTRIMP category showed a higher prevalence of partially calcified, noncalcified, and proximal plaques.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In our study, self-reported MET-min/week showed limited associations with coronary atherosclerosis, whereas objectively measured training load demonstrated more consistent and stronger associations across multiple CAD markers.

    “In our study, self-reported MET-min/week showed limited associations with coronary atherosclerosis, whereas objectively measured TL demonstrated more consistent and stronger associations across multiple CAD markers.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Continuous analyses suggested an approximately linear relationship between objective training load and subclinical CAD, precluding identification of a clear threshold for "high" training load.

    “Continuous analyses suggested an approximately linear relationship between objective TL and subclinical CAD, precluding identification of a clear threshold for “high” TL.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Models were adjusted for traditional cardiovascular risk factors and years of endurance exercise.

    “Models were adjusted for traditional cardiovascular risk factors, including age, body mass index, systolic and diastolic blood pressure, HbA1c, measured LDL (low-density lipoprotein) cholesterol, triglycerides, lipoprotein(a), family history of CAD (defined as a first-degree relative with myocardial infarction before age 50 years in men or 60 years in women), and years of endurance exercise.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Participants were included in the objective training load analysis only if at least 70% of total objectively measured training time was recorded with a heart rate monitor.

    “To ensure adequate capture of training intensity, participants were included in the objective TL analysis if ≥70% of total objectively measured training time was recorded with a HR monitor.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Coronary computed tomography angiography readers were blinded to participants' exercise history.

    “CCTA readers were blinded to participants’ exercise history.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Study design and conductnone given

    Wearable-derived training load data can be processed automatically at scale.

    “Wearable-derived training load data can be processed automatically at scale”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    A timing covariate was included in multivariable logistic regression models to account for potential bias from timing of training load collection, and it was not significantly associated with coronary artery disease characteristics.

    “To account for potential bias caused by timing of TL collection (ie, data collected 12 months before or after CCTA), a timing covariate was included in multivariable logistic regression models. This covariate was not significantly associated with CAD characteristics (Table S7).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Models assessing objective training duration were additionally adjusted for percentage of time spent in high-intensity exercise, and models assessing high-intensity training were adjusted for objective training duration, to isolate independent associations.

    “The models assessing quartiles of objective training duration were in addition adjusted for the percentage of time spent in high-intensity exercise (intensity zones 4 and 5). Similarly, models assessing quartiles of high-intensity training were adjusted for objective training duration. This approach was used to isolate the independent associations of training duration and intensity with CAD.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    The effect of objective training load on coronary artery disease risk remains unknown.

    “The effect of objective TL on CAD risk remains unknown.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    There were no missing data for baseline characteristics or coronary computed tomography angiography data in the cohort of 222 participants.

    “There were no missing data for baseline characteristics or CCTA data in the cohort of 222 participants.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Baseline characteristics of participants with available 12-month wearable training load data (n=222) were comparable with those of the remaining Master@Heart participants without wearable data (n=336), suggesting minimal risk of selection bias.

    “Baseline characteristics of participants with available 12-month wearable TL data (n=222), included in this analysis, were comparable with those of the remaining Master@Heart participants without wearable data (n=336), suggesting minimal risk of selection bias (Table S3).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Repeated exposure to intense exercise may contribute to vascular inflammation and plaque vulnerability, consistent with the finding of more partially calcified and noncalcified plaques in the highest training load quartile.

    “and repeated exposure may contribute to vascular inflammation and plaque vulnerability, consistent with our finding of more partially calcified and noncalcified plaques in the highest TL quartile.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Self-reported training data remain essential for estimating lifetime exposure, whereas objective measures may improve sensitivity for detecting dose-response associations in highly active populations.

    “Self-reported training data remain essential for estimating lifetime exposure, whereas objective measures may improve sensitivity for detecting dose-response associations in highly active populations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Training load for 86 participants was captured during the 12 months after CCTA.

    “Although the majority of objective TL was collected prospectively, TL for 86 participants was captured during the 12 months after CCTA.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The cohort consisted exclusively of White men age 45 to 70 years, limiting the generalizability of findings to women and other ethnicities.

    “The cohort consisted exclusively of White men age 45 to 70 years, limiting the generalizability of findings to women and other ethnicities.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    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”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Berry JD Zabad N Kyrouac D Leonard D Barlow CE Pavlovic A Shuval K Levine BD DeFina LF. High-volume physical activity and clinical coronary artery disease outcomes: findings from the Cooper Center Longitudinal Study. Circulation. 2025; 151: 1299– 1308. doi: 10.1161/circulationaha.124.070335 40255152 source

  • May combine two claims.

    Interpretationown data

    CCTA did not affect training behavior and the data likely reflect consistent long-term training load.

    “indicating that CCTA did not affect training behavior and that the data likely reflect consistent long-term TL.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Plaque features such as noncalcified or partially calcified composition have been linked to greater plaque vulnerability, and proximal lesion location may be associated with larger myocardial territories at risk in the event of an acute coronary syndrome.

    “Plaque features such as noncalcified or partially calcified composition have been linked to greater plaque vulnerability, and proximal lesion location may be associated with larger myocardial territories at risk in the event of an acute coronary syndrome.27”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Golub IS Termeie OG Kristo S Schroeder LP Lakshmanan S Shafter AM Hussein L Verghese D Aldana-Bitar J Manubolu VS. Major global coronary artery calcium guidelines. JACC Cardiovasc Imaging. 2023; 16: 98– 117. doi: 10.1016/j.jcmg.2022.06.018 36599573 source

  • May combine two claims.

    Interpretationown data

    The observed higher prevalence of proximal plaques in high-training-load athletes supports the hypothesis that repeated high-intensity exercise promotes focal atherosclerosis via shear stress.

    “The observed higher prevalence of proximal plaques in high-TL athletes supports this hypothesis.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    These findings raise concern that a subset of middle-aged and older endurance athletes may unknowingly harbor high-risk plaque characteristics, despite a healthy lifestyle and low cardiovascular risk profile as demonstrated by SCORE2.

    “These findings raise concern that a subset of middle-aged and older endurance athletes may unknowingly harbor high-risk plaque characteristics, despite a healthy lifestyle and low cardiovascular risk profile as demonstrated by SCORE2 (Table 1).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Transient increases in parathyroid hormone may promote vascular calcification, aligning with higher CAC observed in athletes.

    “which may promote vascular calcification, aligning with higher CAC observed in athletes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    Occasional training sessions performed without a wearable may lead to minor underestimation of training load, but this bias is expected to be nondifferential.

    “Next, it is possible that occasional training sessions were performed without a wearable, potentially leading to minor underestimation of TL; however, this bias is expected to be nondifferential.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The bias from occasional training sessions performed without a wearable is nondifferential.

  • May combine two claims.

    Premisecitation

    Pavlovic et al found an association between high-duration, low-intensity training and CAC, but used an even lower threshold for "high intensity" (>6 METs).

    “Similarly, Pavlovic et al found an association between high-duration, low-intensity training and CAC, but used an even lower threshold for “high intensity” (>6 METs).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Pavlovic A DeFina LF Leonard D Radford NB Farrell SW Barlow CE Shuval K Berry JD Levine BD. Coronary artery calcification and high-volume physical activity: role of lower intensity vs. longer duration of exercise. Eur J Prev Cardiol. 2024; 31: 1526– 1534. doi: 10.1093/eurjpc/zwae150 38651686 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    These limitations underscore the need for more nuanced training load metrics in highly trained cohorts.

    “These limitations underscore the need for more nuanced TL metrics in highly trained cohorts.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Pavlovic A DeFina LF Leonard D Radford NB Farrell SW Barlow CE Shuval K Berry JD Levine BD. Coronary artery calcification and high-volume physical activity: role of lower intensity vs. longer duration of exercise. Eur J Prev Cardiol. 2024; 31: 1526– 1534. doi: 10.1093/eurjpc/zwae150 38651686 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    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”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Berry JD Zabad N Kyrouac D Leonard D Barlow CE Pavlovic A Shuval K Levine BD DeFina LF. High-volume physical activity and clinical coronary artery disease outcomes: findings from the Cooper Center Longitudinal Study. Circulation. 2025; 151: 1299– 1308. doi: 10.1161/circulationaha.124.070335 40255152 source
48 of 48

  • The paper relies on this without support.

    A 12-month period of wearable-derived training load is representative of the longer-term exercise exposure relevant to subclinical coronary artery disease.

    “TL was objectively measured using wearable device data over a continuous 12-month period to ensure a representative training snapshot.”

  • The paper relies on this without support.

    For participants with only post-coronary computed tomography angiography wearable data, training load in the 12 months after the scan is a valid proxy for training load before the scan.

    “In an additional 86 participants, only post-CCTA data (12 months after the scan) were available and were included to enhance statistical power.”

  • The paper relies on this without support.

    Wearable devices and the TrainingPeaks platform provide comparable and accurate training duration and heart rate data across participants and devices.

    “When wearable devices (eg, sports watches) were connected to the TrainingPeaks platform (Peaksware, Boulder, CO), all training sessions were automatically synchronized without requiring manual uploads by participants.”

  • The authors state this as an assumption.

    Timing of training load data collection did not bias the results.

    “supporting the assumption that timing of TL data collection did not bias the results.”

  • The paper relies on this without support.

    The bias from occasional training sessions performed without a wearable is nondifferential.

    “however, this bias is expected to be nondifferential.”
5 of 5

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Authors
Pauwels, R., Dausin, C., Ruiz-Carmona, S., De Bosscher, R., De Paepe, J., Bekhuis, Y., Delpire, B., Sinnaeve, P., Dymarkowski, S., Ghekiere, O., Bruckers, L., Kuznetsova, T., Van De Heyning, C. M., Van Herck, P. L., Eijsvogels, T. M. H., Herbots, L., Robyns, T., La Gerche, A., Heidbuchel, H., Willems, R., Claessen, G., Bogaert, J., Goetschalckx, K., Claus, P., Fatkin, D., Van Soest, S., Janssens, K., Claeys, M., Hespel, P., Dresselaers, T., Miljoen, H., Favere, K., Paelinck, B., Vermeulen, D., Witvrouwen, I., Hansen, D., Op’t Eijnde, B., Thijs, D., Vanvoorden, P., Lefebvre, K., D’Ambrosio, P., Rowe, S., Mitchell, A. M., Spencer, L., & Duchenne, J.
Affiliations
  • Universitair Ziekenhuis Leuven (BE)
  • KU Leuven (BE)
  • Department of Cardiology (S.R.-C.), Baker Heart and Diabetes Institute, Melbourne, Australia.
  • Department of Cardiovascular Sciences (R.P., R.D.B., J.D.P., Y.B., B.D., P.S., T.K., T.R., R.W., G.C.), Katholieke Universiteit Leuven, Belgium.
  • Department of Cardiology, Hartcentrum (R.P., J.D.P., Y.B., B.D., L.H., G.C.), Jessa Ziekenhuis, Hasselt, Belgium.
  • Jessa Hospital (BE)
  • Hasselt University (BE)
  • Department of Cardiovascular Sciences, University of Antwerp, Belgium (C.M.V.D.H., P.L.V.H., H.H.).
  • Radboud University Nijmegen (NL)
  • Heart, Exercise and Research Trials Laboratory, Saint Vincent’s Institute of Medical Research, Melbourne, Australia (A.L.G.).
Corresponding author
Pauwels, Rik
ORCID
Venue
Circulation
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2026-04-07
Volume
153
Issue
14
Pages
1009-1022
ISSN
  • 0009-7322 (ISSN-L)
  • 1524-4539
DOI
10.1161/circulationaha.125.077117
PMC
PMC13056411
OpenAlex
W7126121193
Semantic Scholar
bacb3102455d2e9c9c62851e07e81f594368dd6a
Cited by
3
References
36
Citations by year
2026: 3
FWCI
14.21
Type
journal article
Language
en
Open access
Licence
Locations
  • Circulation (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Lirias (submittedVersion, other-oa)
  • PubMed Central (submittedVersion, cc-by-nc-nd)
  • Radboud Repository (Radboud University) (submittedVersion)
  • Document Server@UHasselt (UHasselt) (submittedVersion, other-oa)
  • Document Server@UHasselt (UHasselt) (submittedVersion)
Funders
  • Fund for Scientific Research Flanders (T003717N, 1189325N, T004420N)
  • E-Dekker grant (#03-002-2023-0036)
  • FIT-HEART consortium grant (#01-001-2024-0621)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
  • Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
  • Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
Keywords
training load, coronary artery disease, wearable activity trackers, training impulse, coronary artery calcification, endurance athletes, middle-aged and older adults, high-intensity exercise, coronary plaque, cardiovascular risk, heart rate monitoring
MeSH terms
Computed Tomography Angiography, Wearable Electronic Devices, Endurance Training, Aged, Coronary Artery Disease, Cross-Sectional Studies, Humans, Male, Middle Aged, Risk Factors, Exercise, Prevalence, Athletes

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-12.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-12.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

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