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New evidence on the long-term cardiovascular effects of endurance exercise

Comment by Luis Serratosa, EAPC Sports Cardiology Section

Risk Factors and Prevention

The authors of the present article (1) present novel results related with the ongoing debate on the long term cardiovascular effects of lifelong intense endurance exercise. Their initial hypothesis is that athletes that perform more lifelong exercise will demonstrate similar or higher coronary artery calcification (CAC) scores, but with a greater CAC density and more low-risk calcified plaques, instead of non-calcified and mixed plaques, compared to athletes performing lower lifelong exercise volumes. The enhanced plaque calcification could offset the increased CAC score and contribute to the superior longevity of endurance athletes.

This observational study included 284 Dutch Caucasian men (55±7 years) engaged in competitive or recreational leisure sports (cycling 60%, running 56%, soccer 38%, tennis 28%, as the most frequently practiced) from the Measuring Athlete’s Risk of Cardiovascular Events study. Participants were categorized according to their reported lifelong exercise history (<1000 MET-min/week, 1000-2000 MET-min/week or >2000 MET-min/week) and underwent a non-contrast and contrast-enhanced computed tomography scan to assess CAC and plaque characteristics.

Results showed that participants in the most active group (>2000 MET-min/week, 5.7 hrs/week during 40 yrs on average) had a higher prevalence of CAC and atherosclerotic plaques, but with a more benign composition (fewer mixed plaques and more often only calcified plaques) compared to the least active group
(<1000 MET-min/week, 1.5 hrs/week during 27 yrs on average). The authors speculate with some of the potential underlying mechanisms: increased mechanical stress on the vessel wall and altered flow patterns, high blood pressures during exercise, increased levels of parathyroid hormone and/or hypomagnesemia in athletes. They conclude that these observations could explain the increased life expectancy of endurance athletes despite the presence of more coronary atherosclerosis in the most active ones.

Among the limitations of the study, the authors mention having included just Caucasian males, the possible residual confounding factors because of being an observational study, the recall bias associated with the reported exercise history and the absence of a control group.

Merghani et al. found similar results (more coronary plaques but with a stable nature) in a recently published study on 152 masters athletes (54.4±8.5 yrs old; 70% male; 31±12.6 yrs of training in endurance exercise, mostly running) when compared with a group of age and sex matched relatively sedentary controls (2).

These observed differences in plaque morphology between male athletes and less active or sedentary men may indicate different pathophysiological mechanisms for the development of atherosclerosis. Further studies with larger cohorts, including females and individuals of different races will hopefully aid in clarifying the mechanisms and clinical significance of atherosclerosis in athletes with a lifelong history of endurance training. 

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology 


L. Serratosa commented on this article:

1. The relationship between lifelong exercise volume and coronary atherosclerosis in athletes
Aengevaeren VL, Mosterd A, Braber TL, et al.

Circulation 2017; DOI:10.1161/CIRCULATIONAHA.117.027834

Additional reference:

2. Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile, Merghani A, Maestrini V, Rosmini S, et al. 

Circulation. 2017;136:126-137.