Resilience against exercise-related coronary atherosclerosis: A case study in a master athlete participating in 500 marathons

Background and purpose: Lifelong endurance exercise is generally associated with cardiovascular health benefits. However, recent studies suggest that prolonged high-volume training may contribute to coronary atherosclerosis, even in athletes with low traditional cardiovascular risk. This case report aims to explore the cardiovascular status of a master endurance athlete with an exceptionally high lifetime training volume, in light of recent concerns raised in the literature. Methods: We present the case of a 60-year-old recreational male marathon runner with no history of cardiovascular disease, who completed over 500 marathons between the ages of 30 and 60 years, covering ∼127 ​000-km running. In 2024 alone, he completed 60 marathons. Cardiovascular evaluation included clinical risk assessment and coronary computed tomography angiography (CTCA). Results: The runner was asymptomatic, had a low ESC-SCORE2 (3.3%), a favorable lipid profile, and normal levels of high-sensitivity C-reactive protein and lipoprotein (a). CTCA revealed no evidence of calcified, mixed, or non-calcified coronary plaques. Conclusions: This case highlights that some master athletes may demonstrate resilience to coronary atherosclerosis despite decades of high training volume. In low-risk individuals, prolonged endurance training alone may not necessarily lead to coronary artery disease, emphasizing the need for individualized cardiovascular screening strategies.