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. 2025 Jun;4(6 Pt 1):101786.
doi: 10.1016/j.jacadv.2025.101786. Epub 2025 May 14.

Sex Differences in the Impact of Exercise Volume on Subclinical Coronary Atherosclerosis: A Meta-Analysis

Ahmed Abdelaziz  1 , Ahmed Elshahat  1 , Ahmed Farid Gadelmawla  2 , Muhammad Desouky  3 , Abdelrahman H Hafez  1 , Mohamed Abdelaziz  1 , Noha Hammad  4 , Dua Eldosoky  5 , Kirtipal Bhatia  6 , Annalisa Filtz  6 , Daniel Lorenzatti  6 , Toshiki Kuno  7 , Salim S Virani  8 , Martha Gulati  9 , Michel D Shapiro  10 , Carl J Lavie  11 , Leandro Slipczuk  12
Affiliations

Sex Differences in the Impact of Exercise Volume on Subclinical Coronary Atherosclerosis: A Meta-Analysis

Ahmed Abdelaziz et al. JACC Adv. 2025 Jun.

Abstract

Background: The effects of high-volume exercise on coronary atherosclerosis remain controversial.

Objectives: The authors aimed to evaluate the impact of endurance exercise on coronary atherosclerosis assessed by cardiac computed tomography (CT) in athletes and nonathletes, and analyze differences based on sex.

Methods: We searched PubMed, Scopus, Web of Science, and Cochrane Central for relevant studies from inception to September 2024, assessing the impact of different exercise volumes on subclinical coronary artery atherosclerosis assessed by coronary artery calcification (CAC) scoring or CT angiography (CCTA). The control group comprised nonathletes. The primary outcome was the difference in CAC scores between athletes and nonathletes and the secondary outcome was the differences in calcified plaque by CCTA. The analysis was stratified by sex and exercise volume assessed using metabolic equivalents of task (MET)-min/wk.

Results: Nine observational studies including 61,150 participants were included in the analysis. Male athletes with an exercise volume of >3,000 MET-min/wk showed higher mean CAC scores than nonathlete males (mean difference = 31.62; 95% CI: 10.66-52.58; P < 0.001), while no difference in CAC was found for male athletes with 1,500 to 3,000 MET-min/wk (P = 0.93) or female athletes with an exercise volume of 1,500 MET-min/wk or greater (P = 0.39 and P = 0.07). Our secondary endpoint showed significant sex-specific differences on the association of exercise volume and calcified plaque number and volume by CCTA.

Conclusions: Males with high-volume exercise training (>3,000 MET-min/wk) exhibited a higher burden of calcified plaque by CAC score than male nonathletes, while no such difference was observed in female athletes.

Keywords: CAC; athletes; cardiovascular risks; coronary artery calcium; exercise; sex differences; subclinical atherosclerosis.

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Conflict of interest statement

Funding support and author disclosures Drs Lorenzatti, Filtz, and Slipczuk are supported by institutional grants from Amgen and Philips. Dr Gulati has served on the advisory boards of Esperion, Novartis, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
PRISMA Flow Diagram for Study Selection Process for Inclusion in the Meta-Analysis PRISMA = Preferred Reporting Items of Systematic Reviews and Meta-Analysis.
Figure 2
Figure 2
Forest Plot of CAC Score in Males With a Subgroup Analysis on Exercise Volume CAC = coronary artery calcification.
Figure 3
Figure 3
Publication Bias Assessment of CAC Score in Male Athletes and Nonathletes Using DOI Plot Method LFK index = 0.29, indicating no asymmetry is found and no publication bias is detected. Abbreviation as in Figure 2.
Figure 4
Figure 4
Leave-One-Out Sensitivity Analysis in Male Athletes With an Exercise Volume of >3,000 MET-min/wk MET = metabolic equivalent of task.
Figure 5
Figure 5
Forest Plot of CAC Score in Females With a Subgroup Analysis on Exercise Volume Abbreviation as in Figure 2.
Central Illustration
Central Illustration
Sex Differences in the Impact of Exercise Volume on Subclinical Coronary Atherosclerosis: A Meta-Analysis CAD = coronary artery disease; CCTA = coronary computed tomography angiography; CT = computed tomography; other abbreviations as in Figures 2 and 4.
See this image and copyright information in PMC

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