Lifelong Endurance Exercise and Coronary Atherosclerosis

Quick Takes

  • In a prospective, observational cohort study of lifelong endurance athletes, late-onset athletes, and healthy and active but nonathletic men, lifelong athletics was associated with more coronary plaques, including more noncalcified plaques in proximal coronary segments.
  • The study was limited to men who predominantly participated in cycling, and it did not address clinical atherosclerotic coronary events.

Study Questions:

Is there an impact on long-term endurance sport participation in addition to a healthy lifestyle on coronary atherosclerosis plaque extent and/or composition?


The Master@Heart study is a prospective, observational cohort study that includes 191 lifelong master endurance athletes, 191 late-onset athletes (endurance sports initiation after 30 years of age), and 176 healthy nonathletes; all participants are male and have a low cardiovascular risk profile. Peak oxygen uptake (VO2peak) was used to quantify fitness. Computed tomography (CT) and CT angiography (CTA) were used to define plaque composition (calcified areas defined as density >130 HU) and plaque location and severity. The primary endpoint was the prevalence of coronary plaques (calcified, noncalcified, and mixed) on CT/CTA. Analyses were corrected for multiple cardiovascular risk factors.


The median age was 55 (interquartile range [IQR], 50-60) years in all groups. Lifelong and late-onset athletes had higher VO2peak than nonathletes (159 [IQR, 143-177] vs. 155 [IQR, 138-169] vs. 122 [IQR, 108-138] % predicted, p < 0.001). Lifelong endurance sports was associated with having ≥1 coronary plaque (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.17-2.94), ≥1 proximal plaque (OR, 1.96; 95% CI, 1.24-3.11), ≥1 calcified plaque (OR, 1.58; 95% CI, 1.01-2.49), ≥1 calcified proximal plaque (OR, 2.07; 95% CI, 1.28-3.35), ≥1 noncalcified plaque (OR, 1.95; 95% CI, 1.12-3.40), ≥1 noncalcified proximal plaque (OR, 2.80; 95% CI, 1.39-5.65), and ≥1 mixed plaque (OR, 1.78; 95% CI, 1.06-2.99) compared to participants with a healthy and active but nonathletic lifestyle.


Lifelong endurance sports participation was not associated with a more favorable coronary plaque composition compared to a healthy but nonathletic lifestyle. Lifelong endurance athletes had more coronary plaques, including more noncalcified plaques in proximal segments, than did fit and healthy individuals with a similarly low cardiovascular risk profile. The authors conclude that longitudinal research is needed to reconcile these findings with the risk of cardiovascular events at the higher end of the endurance exercise spectrum.


There is ongoing debate about the relationship between long-term endurance exercise and coronary heart disease risk. This prospective, observational study found that lifelong endurance athletes had more coronary plaques compared to healthy and active nonathletes, including more noncalcified plaques and more noncalcified proximal plaques; however, it did not address atherosclerotic coronary clinical events. In this study, all athletes were men, and the predominance were cyclists (77% cyclists or mixed cyclist/runners); potentially limiting extrapolation of the results to other populations. Further, although the presence of plaques was greater among athletes compared to healthy and active nonathletes, the overall plaque burden still was low. Regular exercise is known to improve blood pressure control and lipid profiles, to reduce the incidence of diabetes and myocardial infarction, and to increase life expectancy. Inasmuch as this study provides a cautionary note about endurance athletics and coronary plaque presence, an active lifestyle still should be encouraged, and additional cardiac clinical events still should guide exercise recommendations.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Lipid Metabolism, Interventions and Imaging, Computed Tomography, Nuclear Imaging, Exercise, Sports and Exercise and Imaging

Keywords: Atherosclerosis, Athletes, Computed Tomography Angiography, Coronary Disease, Diagnostic Imaging, Exercise, Healthy Lifestyle, Life Style, Lipids, Myocardial Infarction, Myocardial Ischemia, Oxygen Consumption, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Sports, Tomography

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