Can Intense Exercise Modify the Coronary Atherosclerosis Profile?

While physical activity is a widely accepted recommendation for preventing cardiovascular disease, questions remain regarding the impact of very high volumes of exercise. Some studies in endurance athletes have shown a higher burden of coronary plaque—predominantly calcified and stable—while others have reported an increase in non-calcified or mixed plaque, which are associated with higher risk.

This observational, retrospective cohort study evaluated whether high volumes of exercise modify the profile of coronary artery disease detected by computed tomography angiography (CTA) and clinical events, compared to sedentary individuals. Researchers included a total of 224 symptomatic patients (with angina, dyspnea, or pathological studies suggestive of coronary artery disease) without a prior diagnosis of coronary disease, with low or intermediate pre-test probability, referred for CTA in a real-world clinical setting. The study compared 100 patients with high levels of exercise (≥3–5 times per week and ≥1 hour per session; average weekly volume: 9 hours; average MET: 8.78 ± 3.5) with 124 sedentary control subjects. The mean follow-up was 3.95 ± 1.0 years. Only endurance exercise (such as running, cycling, ski mountaineering, or swimming) was considered; strength training, mixed, and low-intensity activities were excluded.

The primary endpoint was the presence of high-risk plaque (HRP); secondary endpoints included coronary artery calcium (CAC) score, stenosis severity (CAD-RADS), major adverse cardiovascular events (MACE), and the need for revascularization. Both groups were comparable in age (56.7 vs. 58.1 years; p=0.328) and dyslipidemia (48% vs. 54%; p=0.393), although athletes had a lower prevalence of hypertension (37% vs. 54%, p=0.016) and diabetes (5% vs. 13.7%, p=0.032), and lower body mass index (24.3 vs. 28.2 kg/m², p <0.001).

There were no significant differences in CAC score (80.5 vs. 107.7 AU; p=0.820), severity of coronary stenosis (p=0.394), or clinical event rates: death (0% vs. 0.8%), acute coronary syndrome (2% vs. 2.4%), and need for revascularization (7% vs. 10.5%; p=0.501). The prevalence of HRP was lower in the high-exercise group (17% vs. 20.9%; p=0.435), but it did not reach statistical significance, and this difference disappeared after adjusting for risk factors.

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After matching for all cardiovascular risk factors, multivariate analysis and logistic regression models did not show any association between high levels of exercise and the presence of HRP or elevated CAC.

Conclusion

High levels of exercise (an average of 9 hours per week) are not associated with greater severity of coronary stenosis, higher coronary calcium scores, or increased cardiovascular events. On the contrary, they are associated with lower prevalence of diabetes and hypertension, and lower body mass index. This study confirms that even high volumes of non-professional recreational exercise do not produce adverse effects on coronary morphology or plaque characteristics.

Original Title: The influence of high exercise levels on the coronary atherosclerosis profile by computed tomography angiography and outcomes.

Reference: Gudrun M. Feuchtner et al. American Journal of Preventive Cardiology, 2025; doi:10.1016/j.ajpc.2025.101044.