The 2026 ESC/ACC clinical consensus statement on Masters Athletes With Abnormal Cardiovascular Findings is guided by a clinical consensus statement outlining expert recommendations for the diagnostic assessment, management, and risk stratification of cardiac abnormalities in masters athletes (MAs).

MAs, defined as individuals ≥35 years who regularly participate in competitive or high-intensity recreational exercise, derive substantial cardiovascular (CV) benefits from lifelong physical activity. However, emerging evidence suggests that certain CV abnormalities may occur more frequently in MAs than in less-active peers.

Key Findings

• MAs have a higher prevalence and incidence of atrial fibrillation (AF) despite fewer traditional risk factors. Absolute rates are lower in female athletes. Proposed AF mechanisms include atrial dilation, autonomic changes, electrical conduction slowing, and atrial fibrosis.
• Rhythm-control strategies are often preferred because beta-blockers and other rate-control therapies may impair exercise performance or be poorly tolerated. Whether detraining reduces AF recurrence rates is unknown, and anticoagulation criteria are similar to those for nonathletes.
• Sinus bradycardia, first-degree atrioventricular block, and Mobitz type I block are common findings in endurance athletes.
• Ventricular arrhythmias are not normal training adaptations. Although one premature ventricular contraction (PVC) on a resting electrocardiogram of typical morphology (i.e., outflow tract or fascicular) does not require further evaluation, more than one typical PVCs, an atypical PVC, or symptomatic PVCs should prompt further evaluation.
• Male endurance MAs have a higher prevalence of coronary artery calcification and atherosclerosis than do sedentary peers. The presence of a high coronary artery calcium (CAC) score, in the absence of concerning symptoms, does not require restrictions. There are no data to support empiric aspirin prior to competition.
• Higher cardiorespiratory fitness attenuates—but does not eliminate—the CV risk associated with elevated CAC scores.
• Small, focal myocardial fibrosis at the right ventricle (RV) insertion points on cardiac MRI is often benign, whereas extensive fibrosis or RV-predominant abnormalities may suggest cardiomyopathy.

Overall, CV assessment in MAs requires careful distinction between physiologic exercise adaptation and clinically significant pathology.

CV Imaging Considerations for MAs²

This review by Phelan et al. published in JACC: Cardiovascular Imaging provides the framework for multimodality CV imaging in MAs. The authors emphasize the importance of distinguishing physiologic, exercise-induced remodeling from occult CV disease in this growing population.

Key Points in Imaging and Clinical Evaluation

• Significant exercise-induced remodeling is generally seen only in athletes with high training loads, not recreationally active older adults.
• Although younger athletes are more likely to have inherited cardiomyopathies and channelopathies, MAs are more likely to have coronary artery disease (CAD), AF, myocardial scar, and valvular degeneration.
• CAD is the leading cause of sudden cardiac arrest in MAs.
• Transthoracic echocardiography is first-line imaging in symptomatic athletes with exercise intolerance.
• Exercise stress testing should be sport specific and achieve peak fatigue or symptom reproduction; standard protocols (i.e., the Bruce protocol) and pharmacological stress protocols are often inadequate for physiologic assessment.
• Although some degree of RV remodeling is possible, pathological RV dilation, RV dysfunction, dyskinesis, and ventricular arrhythmias are red flags.
• Malignant features of an enlarged aorta include dilation >44 mm, family history of aortic disease, and features of connective tissue disease.
• Caution is warranted in interpreting fractional flow reserve in MAs because these techniques do not replicate the supply/demand mismatch seen at peak exercise.
• Incidentally detected coronary artery anomalies are often benign and should not be overinterpreted without clinical context.

Cardiac MRI Considerations

• Focal fibrosis (RV insertion points) without structural abnormalities is typically benign.
• Striae or ischemic-pattern late gadolinium enhancement suggests pathological remodeling and warrants further evaluation.
• Left atrial enlargement is common and, when proportional to other chambers, is not inherently pathologic.

Overall, careful interpretation of multimodality imaging is essential to differentiate physiologic adaptation from occult disease in MAs.

Longitudinal Study of Endurance Athletes on CV Adaptation to Training Load³

This study published by Dausin et al. in European Heart Journal evaluated whether exercise intensity or total training volume is the primary determinant of physiological cardiac remodeling in endurance athletes using objective wearable-derived training data and cardiac MRI.

The cohort included 151 male endurance athletes, classified as young (16-23 years of age) and middle-aged (45-70 years of age), from the Pro@Heart Consortium. Inclusion required ≥80% of training sessions recorded via chest-worn heart rate monitors over a 3-month period. Training load was quantified using total duration, session count, heart rate zones, and a composite intensity-duration metric (Edwards training impulse [eTRIMP]). Cardiac MRI was used to assess indexed left ventricular (LV) and RV volumes and LV mass.

A clear graded relationship was observed between training load and cardiac remodeling, with progressive increases in ventricular volumes and myocardial mass across quartiles of exercise exposure and eTRIMP.

Key Findings

• Progressive, stepwise increases were seen in LV end-diastolic volume index (EDVi), LV end-systolic volume index (ESVi), RV EDVi, RV ESVi, and LV mass index across increasing training load quartiles.
• A similar dose-response relationship was observed with eTRIMP, supporting a cumulative exercise effect.
• Total training duration was the strongest independent predictor of cardiac remodeling, exceeding both intensity and session frequency.
• Time spent in lower heart rate zones (zones 1-2) showed the strongest association with chamber enlargement.
• Higher-intensity training contributed less to structural remodeling than expected.

Overall, the findings demonstrate that cumulative training volume, not exercise intensity, is the dominant determinant of physiologic cardiac remodeling in endurance athletes.

Physical Activity Volume vs. Intensity and CV/Non-CV Chronic Disease Risk⁴

This large, population-based observational cohort study published by Wei et al. in European Heart Journal examined whether the proportion of physical activity performed at vigorous intensity (%VPA), independent of total activity volume, is associated with risk of major chronic diseases and all-cause death.

The analysis included UK Biobank participants 40-69 years of age with both wrist-worn accelerometer data and questionnaire-based physical activity assessments. Participants were categorized by %VPA (0%, >0-2%, >2-4%, >4%). Outcomes included major adverse cardiovascular events (MACE), AF, type 2 diabetes mellitus, immune-mediated inflammatory diseases, metabolic dysfunction–associated steatosis liver disease, chronic respiratory disease, chronic kidney disease, dementia, and all-cause death, with median follow-up ranging from 8.8 to 14.6 years depending on outcome.

Key Findings

• Higher %VPA was associated with progressively lower risk of all-cause death and all major chronic diseases studied.
• Compared with 0% VPA, >4% VPA was associated with risk reductions of all eight chronic diseases studied, including all-cause death.
• Associations were independent of total physical activity volume.
• 5-year MACE risk decreased from 10.16% (0% VPA) to 6.41% (>4% VPA).

Although the findings of this large observational cohort study provide valuable insights into the protective benefits of vigorous exercise being independently associated with a reduced risk of multiple chronic diseases and death, they were limited by an observational design that precluded establishing direct causality.

References

1. Eijsvogels TMH, Kim JH, Aengevaeren VL, et al. Masters athletes with abnormal cardiovascular findings: a clinical consensus statement of the European Association of Preventive Cardiology of the ESC and the American College of Cardiology. J Am Coll Cardiol. 2026;88(3):389-411. doi:10.1016/j.jacc.2026.03.025
2. Phelan DM, Claessen G, Eijsvogels TMH, et al. Cardiovascular imaging considerations for masters-aged athletes. JACC Cardiovasc Imaging. 2026;19(4):538-550. doi:10.1016/j.jcmg.2025.10.024
3. Dausin C, Ruiz-Carmona S, Cauwenberghs N, et al. Cardiovascular adaptation to training load in endurance athletes: a longitudinal study. Eur Heart J. Published online January 7, 2026. doi:10.1093/eurheartj/ehaf1018
4. Wei J, Shen M, Li S, et al. Volume vs intensity of physical activity and risk of cardiovascular and non-cardiovascular chronic diseases. Eur Heart J. Published online March 29, 2026. doi:10.1093/eurheartj/ehag168