Occult coronary artery disease in middle-aged sportsmen with a low cardiovascular risk score: The Measuring Athlete’s Risk of Cardiovascular Events (MARC) study

Braber, Thijs L; Mosterd, Arend; Prakken, Niek H J; Rienks, Rienk; Nathoe, Hendrik M.; Mali, Willem P.Th.M.; Doevendans, Pieter A.; Backx, Frank; Bots, Michiel L.; Grobbee, Diederick E.; Velthuis, Birgitta K.

doi:10.1177/2047487316651825

Cited by 59 publications

(74 citation statements)

References 44 publications

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“…The number of male athletes with a CAC=0 in this study was significantly higher than in a previous study from Germany of 108 middle-age marathon runners of similar age but higher risk profile 8 and slightly higher than a Dutch study of 318 asymptomatic athletic men with a generally low risk profile where 37% were former or current smokers. 10 The percentage of male athletes with a CAC >100 Agatston units was also lower in our study compared with the German marathon runners (18.9% versus 36.1%). 8 These observations suggest that the higher coronary calcium scores in previous studies likely reflected a higher atherosclerotic risk profile rather than a potentially deleterious exercise effect.…”

Section: Discussioncontrasting

confidence: 48%

“…Ultra-endurance athletes have also been reported to have a greater vasodilatory capacity compared with sedentary individuals. 29 In contrast, 3 previous studies have shown a higher burden of atherosclerosis in endurance athletes compared with controls, [8][9][10] raising concerns that prodigious amounts of exercise may actually accelerate the coronary atherosclerotic process. These studies included athletes with established risk factors for CAD or could not exclude the possibility that many of them had adopted an active lifestyle in middle age and had higher risk factors during most of their lives.…”

Section: Discussionmentioning

confidence: 95%

“…These studies generate controversy because, although exercise is associated with a reduction in adverse events from CAD, coronary atherosclerosis is also the most common cause of exercise-related sudden death in masters athletes. [12][13][14][15][16] However, existing studies are limited by small sample sizes, focus on men only, [8][9][10][11][12] and inclusion of athletes with risk factors for atherosclerosis. [8][9][10][11][12] Only 1 of these major studies has demonstrated increased atherosclerosis in the athletes after adjusting for their lower Framingham risk scores.…”

mentioning

confidence: 99%

“…7 Although ostensibly fit and healthy, several studies have reported high coronary artery calcium (CAC) scores [8][9][10] and myocardial fibrosis 11,12 in such athletes. These studies generate controversy because, although exercise is associated with a reduction in adverse events from CAD, coronary atherosclerosis is also the most common cause of exercise-related sudden death in masters athletes.…”

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confidence: 99%

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Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile

et al. 2017

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BACKGROUND: Studies in middle-age and older (masters) athletes with atherosclerotic risk factors for coronary artery disease report higher coronary artery calcium (CAC) scores compared with sedentary individuals. Few studies have assessed the prevalence of coronary artery disease in masters athletes with a low atherosclerotic risk profile. METHODS:We assessed 152 masters athletes 54.4±8.5 years of age (70% male) and 92 controls of similar age, sex, and low Framingham 10-year coronary artery disease risk scores with an echocardiogram, exercise stress test, computerized tomographic coronary angiogram, and cardiovascular magnetic resonance imaging with late gadolinium enhancement and a 24-hour Holter. Athletes had participated in endurance exercise for an average of 31±12.6 years. The majority (77%) were runners, with a median of 13 marathon runs per athlete. RESULTS:Most athletes (60%) and controls (63%) had a normal CAC score. Male athletes had a higher prevalence of atherosclerotic plaques of any luminal irregularity (44.3% versus 22.2%; P=0.009) compared with sedentary males, and only male athletes showed a CAC ≥300 Agatston units (11.3%) and a luminal stenosis ≥50% (7.5%). Male athletes demonstrated predominantly calcific plaques (72.7%), whereas sedentary males showed predominantly mixed morphology plaques (61.5%). The number of years of training was the only independent variable associated with increased risk of CAC >70th percentile for age or luminal stenosis ≥50% in male athletes (odds ratio, 1.08; 95% confidence interval, 1.01-1.15; P=0.016); 15 (14%) male athletes but none of the controls revealed late gadolinium enhancement on cardiovascular magnetic resonance imaging. Of these athletes, 7 had a pattern consistent with previous myocardial infarction, including 3(42%) with a luminal stenosis ≥50% in the corresponding artery. CONCLUSIONS:Most lifelong masters endurance athletes with a low atherosclerotic risk profile have normal CAC scores. Male athletes are more likely to have a CAC score >300 Agatston units or coronary plaques compared with sedentary males with a similar risk profile. The significance of these observations is uncertain, but the predominantly calcific morphology of the plaques in athletes indicates potentially different pathophysiological mechanisms for plaque formation in athletic versus sedentary men. Coronary plaques are more abundant in athletes, whereas their stable nature could mitigate the risk of plaque rupture and acute myocardial infarction. Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile© 2017 American Heart Association, Inc. ORIGINAL RESEARCH ARTICLE R egular exercise confers a low risk profile for atherosclerosis and is associated with a 50% reduction in adverse events from coronary artery disease (CAD).1,2 The amount of physical activity required to achieve these benefits is 150 minutes of moderate exercise per week. [3][4][5][6] In contrast, some athletes engage in several hours of intensive training p...

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Section: Discussioncontrasting

confidence: 48%

Section: Discussionmentioning

confidence: 95%

mentioning

confidence: 99%

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confidence: 99%

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Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile

et al. 2017

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“…CACS and CTCA have proven predictive value for MI and SCD over clinical risk stratification 83 84. In a recent study of 318 asymptomatic male athletes aged over 45 years, CT identified occult CAD in 19%, where exercise ECG testing was negative during a high work load 85. Other studies suggest that CACS improves prediction of MI or death due to CAD only in intermediate-risk patients (Framingham Risk Score 10%–20%)86 but adds no predictive power for those with low risk (Framingham Risk Score <10%) as assessed by traditional cardiovascular disease risk factors 86–88.…”

Section: Future Directions In the Management Of Mature Athletesmentioning

confidence: 99%

Management of mature athletes with cardiovascular conditions

D’Silva

Sharma

2017

Heart

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Association of All-Cause and Cardiovascular Mortality With High Levels of Physical Activity and Concurrent Coronary Artery Calcification

et al. 2019

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IMPORTANCE Few data are available to guide clinical recommendations for individuals with high levels of physical activity in the presence of clinically significant coronary artery calcification (CAC). OBJECTIVE To assess the association among high levels of physical activity, prevalent CAC, and subsequent mortality risk. DESIGN, SETTING, AND PARTICIPANTS The Cooper Center Longitudinal Study is a prospective observational study of patients from the Cooper Clinic, a preventive medicine facility. The present study included participants seen from January 13, 1998, through December 30, 2013, with mortality follow-up through December 31, 2014. A total of 21 758 generally healthy men without prevalent cardiovascular disease (CVD) were included if they reported their physical activity level and underwent CAC scanning. Data were analyzed from September 26, 2017, through May 2, 2018. EXPOSURES Self-reported physical activity was categorized into at least 3000 (n = 1561), 1500 to 2999 (n = 3750), and less than 1500 (n = 16 447) metabolic equivalent of task (MET)-minutes/week (min/wk). The CAC scores were categorized into at least 100 (n = 5314) and less than 100 (n = 16 444) Agatston units (AU). MAIN OUTCOMES AND MEASURES All-cause and CVD mortality collected from the National Death Index Plus. RESULTS Among the 21 758 male participants, baseline mean (SD) age was 51.7 (8.4) years. Men with at least 3000 MET-min/wk were more likely to have prevalent CAC of at least 100 AU (relative risk, 1.11; 95% CI, 1.03-1.20) compared with those accumulating less physical activity. In the group with physical activity of at least 3000 MET-min/wk and CAC of at least 100 AU, mean (SD) CAC level was 807 (1120) AU. After a mean (SD) follow-up of 10.4 (4.3) years, 759 all-cause and 180 CVD deaths occurred, including 40 all-cause and 10 CVD deaths among those with physical activity of at least 3000 MET-min/wk. Men with CAC of less than 100 AU and physical activity of at least 3000 MET-min/wk were about half as likely to die compared with men with less than 1500 MET-min/wk (hazard ratio [HR], 0.52; 95% CI, 0.29-0.91). In the group with CAC of at least 100 AU, men with at least 3000 MET-min/wk did not have a significant increase in all-cause mortality (HR, 0.77; 95% CI, 0.52-1.15) when compared with men with physical activity of less than 1500 MET-min/wk. In the least active men, those with CAC of at least 100 AU were twice as likely to die of CVD compared with those with CAC of less than 100 AU (HR, 1.93; 95% CI, 1.34-2.78). CONCLUSIONS AND RELEVANCE This study suggests there is evidence that high levels of physical activity (Ն3000 MET-min/wk) are associated with prevalent CAC but are not associated with increased all-cause or CVD mortality after a decade of follow-up, even in the presence of clinically significant CAC levels.

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Occult coronary artery disease in middle-aged sportsmen with a low cardiovascular risk score: The Measuring Athlete’s Risk of Cardiovascular Events (MARC) study

Cited by 59 publications

References 44 publications

Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile

Prevalence of Subclinical Coronary Artery Disease in Masters Endurance Athletes With a Low Atherosclerotic Risk Profile

Management of mature athletes with cardiovascular conditions

Association of All-Cause and Cardiovascular Mortality With High Levels of Physical Activity and Concurrent Coronary Artery Calcification

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