Cardiovascular Imaging Considerations for Masters-Aged Athletes
Key result
Multimodality imaging guides risk stratification in Masters athletes by differentiating athletic remodeling from cardiac disease.
JACC. Cardiovascular imaging published a graphical abstract
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Why the study?
Classical tenets in sports cardiology derived from young competitive athletes do not fully generalize to masters athletes, creating a need for guidance on multimodality cardiovascular imaging.
Key Points
- To review unique physiological and pathologic considerations in masters athletes aged 35 years or older and establish best-practice multimodality cardiovascular imaging strategies for clinical risk stratification and management.
- Synthesized evidence evaluating cardiovascular remodeling, acquired cardiovascular disease risks, and multimodality imaging applications in masters athletes (individuals ≥35 years of age engaged in competitive or high-volume recreational exercise).
- Compared classical exercise physiology paradigms derived from young athletes with the distinct pathophysiology and age-related remodeling observed in older athletic cohorts.
- Assessed specific diagnostic roles and cutoffs for transthoracic echocardiography, cardiac magnetic resonance, and exercise stress imaging modalities.
- Coronary artery disease is the leading cause of sudden cardiac arrest and death in masters athletes, differentiating their primary clinical risk profile from younger athletes who predominantly exhibit inherited channelopathies and cardiomyopathies.
- Endurance-trained masters athletes characteristically demonstrate modest biventricular dilation, mild left ventricular wall thickening (upper limit of normal ≤12-13 mm), and preserved diastolic function, whereas pathological remodeling is indicated by wall thickness ≥15 mm, left ventricular ejection fraction <45%, or global longitudinal strain less negative than −15%.
- Standard exercise protocols fail to replicate athletic training intensity; therefore, sport-specific protocols achieving peak volitional fatigue paired with imaging are recommended to assess dynamic obstruction, ischemia, and functional capacity.
Structured PICO
P
Population
Masters athletes (MAs), defined as individuals ≥35 years of age who engage in organized, competitive, or high-volume or high-intensity recreational sports.
I
Intervention
Multimodality cardiovascular imaging (including transthoracic echocardiography, coronary computed tomography angiography, and cardiac magnetic resonance imaging)
This state-of-the-art review serves as the first dedicated reference on best practice considerations for the use of multi-modality cardiovascular imaging specific to masters athletes.
Limitations
- Data from Masters athletes remain limited, with most normative data derived from young cohorts.
- Lack of diversity in terms of sex, race, and ethnicity in current studies.
- Optimal use of imaging to distinguish between adaptive and maladaptive cardiovascular remodeling remains poorly defined.
- Current understanding of the relationships among MAs, cardiac risk, and cardiovascular phenotypes comes from studies that lack diversity in terms of sex, race, and ethnicity.
- Comprehensive characterization of MA exercise-induced cardiac remodeling remains incomplete.
- The impact of aging, years of athletic training, and the presence of underlying cardiovascular risk factors and/or diseases on MA exercise-induced cardiac remodeling is poorly understood.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“It's similar with almost any patient cared for in the sports cardiology world, but there are certainly nuances in this [older] population. Mixed in with that is that cardiorespiratory fitness is indeed cardioprotective, but it doesn't completely exonerate the development of cardiac risk factors and even the development of cardiac disease.”
Implication
May warrant age-adjusted imaging interpretation in masters athletes; extends sports cardiology literature beyond young athletes but leaves prospective validation open.
Abstract
Masters athletes (MAs), defined as individuals ≥35 years of age who are engaged in competitive or high-volume recreational sports or exercise training, comprise a growing group regularly cared for in sports cardiology. The cardiovascular care of MAs can be challenging because many of the classical tenets in sports cardiology and exercise physiology were derived from young, competitive athletes and therefore do not fully generalize to the care of MAs. Appropriate implementation of multimodality cardiovascular imaging is essential to guide the risk stratification and clinical management of MAs. In this state-of-the-art review, physiological and pathologic considerations unique to MAs are highlighted. The strengths and limitations of specific cardiovascular imaging modalities are reviewed along with guidance on their appropriate use in the care of MAs. The purpose of this document is to represent the first primary reference on best practice considerations for the use of multi-modality cardiovascular imaging in the care of MAs.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Discussion
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Cite This Study
Phelan et al. (2025) conducted a review in Cardiovascular disease in Masters athletes. Multimodality cardiovascular imaging was evaluated. Multimodality cardiovascular imaging is essential to guide the risk stratification and clinical management of Masters athletes by distinguishing physiological adaptation from acquired disease.