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Undertaking lifelong endurance exercise linked to unfavourable coronary plaque composition

Undertaking lifelong endurance exercise gives rise to more risk-prone non-calcified coronary plaques compared to fit and healthy individuals

The findings of a prospective study by the Master@Heart Consortium has revealed that participation in lifelong endurance exercise, gives rise to a more unfavourable coronary plaque profile compared to healthy and active non-athletes.

It is generally accepted that undertaking regular physical activity such as walking, running, or swimming, induces favourable cardiovascular adaptations that prevent the development of coronary artery disease and reduces symptoms in patients with established cardiovascular disease. In fact, heavy physical exertion is known to trigger the onset of acute myocardial infarction, particularly in people who are habitually sedentary. Work with athletes however, has revealed how those with the highest exercise volumes more often have coronary artery calcification and atherosclerotic plaques, although these plaques are of a more benign composition.

In the current study, researchers wanted to better understand the apparent paradox of greater coronary atherosclerosis among those undertaking endurance exercise yet fewer cardiovascular adverse events. They hypothesised that such individuals were likely to have a more favourable plaque composition, i.e., a reduced prevalence of non-calcified and mixed plaques, which could therefore explain the lower risk of cardiovascular events. The researchers studied lifelong endurance athletes, those who undertook endurance exercise but after the age of 30 and heathy, non-athletic individuals. The primary endpoint of the study was the prevalence of coronary plaques (calcified, mixed, and non-calcified) on computed tomography coronary angiography and these findings were adjusted for several cardiovascular risk factors.

Endurance exercise and coronary plaques

A total of 191 lifelong endurance athletes, 191 late-onset athletes and 176 healthy non-athletes, all male with a low cardiovascular risk profile, with a median age of 55 years were included.

Compared to healthy controls, lifelong endurance exercise was associated with the presence of ≥1 coronary plaque (odds ratio, OR = 1.86, 95% 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 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).

Taken together, the authors concluded that participation in lifelong endurance exercise was not associated with a more favourable coronary plaque composition compared to those with a healthy lifestyle. They called for further research to reconcile these findings with the risk of cardiovascular events at the higher end of the endurance exercise spectrum.

De Bosscher R et al. Lifelong endurance exercise and its relation with coronary atherosclerosis. Eur Heart J 2023

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