Coronary atherosclerosis in athletes: emerging concepts and preventive strategies

Abstract

There should be no assumption that an athlete is immune to coronary artery disease (CAD), even when traditional cardiovascular (CV) risk factors appear well-managed. Excelling in certain aspects of health does not equate to total CV protection. Recent data from cardiac imaging studies have raised the possibility that long-term, high-volume, high-intensity endurance exercise is associated with coronary atherosclerosis. Whilst the risk of CV events has not been shown to rise with athletic activity, the potential for CAD should not be overlooked as it is the leading cause of sudden cardiac death in athletes >35 years of age (i.e. 'Masters athletes'). Evaluating both traditional and non-traditional risk factors for CAD is the most important part of pre-participation evaluation in Masters athletes. When managing athletes at risk of CAD it is important to adopt a shared decision-making approach regarding lifestyle adaptation and lipid-lowering treatments. In the great majority of athletes, after excluding the presence of symptoms and inducible ischaemia, this advice should include encouragement to continue exercising as available data indicate that higher levels of fitness are associated with a markedly attenuated incidence of coronary events regardless of the severity of coronary disease. Future research is needed to establish the relationship between clinically relevant CAD outcomes and coronary artery calcification in Masters Athletes, the role of sex, as well as exploration of the mechanisms underpinning these unexpected CV adaptations.

Keywords: Athletes; Cardiovascular risk; Coronary atherosclerosis; Coronary computed tomography angiography; Exercise; Ischaemic heart disease; Sudden cardiac death.

Graphical Abstract

Evaluation and management of athletes at risk of coronary atherosclerosis. CAC, coronary artery calcification; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; PTH, parathyroid hormone.

Figure 1

Case presentation of a 44-year-old previous Tour de France cyclist with chest pain and abnormal exercise stress test. Resting 12-lead electrocardiogram (A), electrocardiogram during exercise (B), and early recovery (C) showing manifest ST-segment elevation (black arrowheads) in leads V2–V6 and leads I and aVL. (D) Coronary angiogram with a significant proximal left anterior descending lesion (white arrow)

Figure 2

Prevalence of coronary artery calcification scores in studies comparing male athletes with controls.^, Prevalence of coronary artery calcification scores >0 within athletic and control subjects (A). (B) Prevalence of coronary artery calcification scores >100. (C) Prevalence of coronary artery calcification scores >400

Figure 3

Prevalence of coronary artery plaques in studies comparing male athletes with controls. Percentage of athletic and non-athletic individuals with ≥1 coronary artery plaque (A). (B) Percentage of calcified plaques in individuals with coronary plaques. (C) Percentage of coronary plaques with >50% stenosis amongst individuals with coronary plaques

Figure 4

Distribution of plaque type in male athletes and non-athletic controls of the Master@Heart study and the paper by Merghani et al.

Figure 5

The relationship between lifetime endurance exercise dose and coronary atherosclerosis by non-invasive coronary imaging in male athletes

Figure 6

Relationship between habitual heavy physical activity (PA) and acute risk of acute myocardial infarction during acute vigorous exercise bouts (left y-axis). The right y-axis depicts the mortality hazard ratio estimates of exercise levels compared with the recommended minimum leisure-time physical activity of 7.5 metabolic equivalent hours per week. Adapted from data by Mittleman et al. and Arem et al.

Figure 7

Mechanisms of sports-related sudden cardiac death due to coronary artery disease. Demand ischaemia is a recognized mechanism for ventricular arrhythmias and/or sudden cardiac death in athletes, driven by the myocardium’s work/metabolic requirements during intense exercise

Figure 8

Cardiovascular event rates plotted with respect to cardiorespiratory fitness and coronary artery calcification score. Adapted from Radford et al.