The Spectrum of Coronary Artery Disease in Elite Endurance Athletes-A Long-Standing Debate: State-of-the-Art Review

Abstract

Physical activity is recommended for the prevention of primary and secondary cardiovascular (CV) disease as it is linked to a number of health benefits, especially CV. However, recent research suggests that high-volume, long-term endurance exercise may hasten rather than slow the coronary atherosclerosis progression. This contentious theory has generated a great discussion and is still a major source of doubt when it comes to the clinical treatment of coronary artery disease (CAD) in athletes. CAD is the primary cause of sudden cardiac death in athletes over 35 years. Thus, recent studies evaluated the prevalence of CAD in athletes and its clinical and prognostic implications. Indeed, many studies have shown a relationship between endurance sports and higher volumes of coronary calcified plaque as determined by computed tomography. However, the precise pathogenetic substrate for the existence of an increased coronary calcification burden among endurance athletes remains unclear. Moreover, the idea that coronary plaques in elite athletes present a benign morphology has been cast into doubt by some recent studies showing potential association with adverse cardiovascular events. This review aims to analyze the association between physical activity and CAD, explaining possible underlying mechanisms of atherosclerotic progression and non-ischemic coronary lesions, focusing primarily on clinical and prognostic implications, multimodal evaluation, and management of CAD in endurance athletes.

Keywords: chronic coronary syndrome; coronary artery disease; coronary plaque; elite athletes; endurance athletes.

Figure 1

Mechanisms of exercise-related coronary atherosclerosis in athletes and contributing factors. PTH = parathyroid hormone.

Figure 2

Special subgroups of coronary anomalies and lesions in elite athletes. (A) coronary artery anomalies (B) Spontaneous coronary artery dissection (C) Myocardial bridging. IVUS = intravascular ultrasound, CABG = coronary artery bypass graft, CCTA = coronary computed tomography angiography, CMR = cardiac magnetic resonance, FFR = fractional flow reserve, iFR = instantaneous wave-free ratio, OCT = optical coherence tomography, PCI = percutaneous coronary intervention, TTE = transthoracic echocardiography.