Lifelong endurance exercise and its relation with coronary atherosclerosis

Abstract

Aims: The impact of long-term endurance sport participation (on top of a healthy lifestyle) on coronary atherosclerosis and acute cardiac events remains controversial.

Methods and results: The Master@Heart study is a well-balanced prospective observational cohort study. Overall, 191 lifelong master endurance athletes, 191 late-onset athletes (endurance sports initiation after 30 years of age), and 176 healthy non-athletes, all male with a low cardiovascular risk profile, were included. Peak oxygen uptake quantified fitness. The primary endpoint was the prevalence of coronary plaques (calcified, mixed, and non-calcified) on computed tomography coronary angiography. Analyses were corrected for multiple cardiovascular risk factors. The median age was 55 (50-60) years in all groups. Lifelong and late-onset athletes had higher peak oxygen uptake than non-athletes [159 (143-177) vs. 155 (138-169) vs. 122 (108-138) % predicted]. 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 plaques (OR 1.58, 95% CI 1.01-2.49), ≥ 1 calcified proximal plaque (OR 2.07, 95% CI 1.28-3.35), ≥ 1 non-calcified plaque (OR 1.95, 95% CI 1.12-3.40), ≥ 1 non-calcified proximal plaque (OR 2.80, 95% CI 1.39-5.65), and ≥1 mixed plaque (OR 1.78, 95% CI 1.06-2.99) as compared to a healthy non-athletic lifestyle.

Conclusion: Lifelong endurance sport participation is not associated with a more favourable coronary plaque composition compared to a healthy lifestyle. Lifelong endurance athletes had more coronary plaques, including more non-calcified plaques in proximal segments, than fit and healthy individuals with a similarly low cardiovascular risk profile. Longitudinal research is needed to reconcile these findings with the risk of cardiovascular events at the higher end of the endurance exercise spectrum.

Keywords: Athlete’s heart; Computed tomography coronary angiography; Coronary artery disease; Exercise.

Structured Graphical Abstract

The Master@Heart study compared the prevalence of calcified, mixed, and non-calcified coronary plaques by computed tomography between 176 controls, 191 late-onset endurance athletes, and 191 lifelong endurance athletes, in the absence of established risk factors for coronary artery disease. Lifelong endurance athletes had the highest coronary plaque burden regardless of plaque types.

Figure 1

Inclusion and exclusion flow chart of the Master@Heart study: the inclusion criteria for all participants were male sex and age between 45 and 70 years. Athletes were defined as follows: questionnaire reported engagement in cycling ≥8 h or running ≥ 6 h per week, or triathlon (combination of swimming, cycling, and running) ≥ 8 h per week for at least 6 months prior to baseline. Non-athletes were defined by engagement in ≤ 3 h per week of physical activity without prior exposure to regular endurance exercise. Exclusion criteria were a medical history of cardiovascular disease, current or past history of smoking, use of any antidiabetic drugs, statins or antihypertensive drugs, a BMI >27.2 kg/m², and a known allergy for iodine contrast agents.

Figure 2

Overall coronary atherosclerotic burden: the overall coronary atherosclerotic burden between lifelong athletes, late-onset athletes, and non-athletic controls presented by (A) the Agatston coronary artery calcium score, (B) the number of plaques per individual, the prevalence of participants with (C) ≥ 1 coronary plaque, (D) ≥ 50% stenosis, (E) ≥ 1 proximal coronary plaque, and (F) the distribution of plaque types. Odds ratios and between-group differences are adjusted for age, body mass index, systolic and diastolic blood pressure, total cholesterol, LDL cholesterol, HbA1c, and family history of coronary artery disease.

Figure 3

Coronary atherosclerotic burden by plaque type. The coronary atherosclerotic burden by ≥1 proximal (A) calcified, (C) non-calcified, and (E) mixed plaques as well as by ≥50% stenosis by (B) calcified, (D) non-calcified, and (F) mixed plaques. Odds ratios are adjusted for age, body mass index, systolic and diastolic blood pressure, total cholesterol, LDL cholesterol, HbA1c, and family history of coronary artery disease.