Coronary Atherosclerosis in Masters Athletes: Contemporary Evidence and Clinical Implications

Purpose of Review A growing body of evidence suggests that Masters athletes have a higher prevalence of coronary artery calcification and plaque compared to more sedentary, but low-risk individuals. This clinical paradox has sparked interest in understanding underlying mechanisms, prognostic importance, and clinical management of coronary atherosclerosis in highly-trained Masters athletes. Recent Findings Data from multiple observational studies evaluating coronary atherosclerosis in Masters athletes have demonstrated a higher-than-expected prevalence of calcified plaque. More recent studies have also identified a greater burden of mixed plaques in Masters athletes, the prognostic significance of which remains uncertain. In parallel, contemporary exercise guidelines for Masters athletes with coronary atherosclerosis have evolved and emphasize shared decision-making, while also taking into account the Masters athlete’s overall cardiovascular risk profile. Summary In this review, we summarize the contemporary evidence on the epidemiology and plaque features of coronary atherosclerosis in Masters athletes, including sex differences and the impact of exercise intensity and traditional cardiovascular risk factors. We review potential mechanisms, including the effects of hemodynamic stress, oxidative stress, inflammation, calcium homeostasis, and genetic factors, as well as their interaction with classic risk factors. Finally, we review current clinical approaches to risk assessment and treatment options, highlighting recent shifts toward personalized assessments and shared decision-making. Graphical Abstract Coronary Atherosclerosis in Masters Athletes. Abbreviations: CAC, Coronary artery calcium; MA, Masters athlete; ROS, Reactive oxygen species; ASCVD, Atherosclerotic cardiovascular disease; CCTA, Coronary computed tomography angiography; BP, Blood pressure; DM, Diabetes mellitus; LDL, Low-density lipoprotein