Coronary CT angiography in master athletes: Redefining primary prevention of ischemic heart disease beyond the Italian 2023 COCIS guidelines

BACKGROUND: In adults over 35 years of age, ischemic heart disease (IHD) is the predominant cause of exercise-related acute coronary events and sudden cardiac death. Master athletes, despite high levels of fitness, are not immune to coronary atherosclerosis, which often remains clinically silent until precipitated by exertional stress. Recent data challenge the assumption that long-term endurance training offers protection against coronary artery disease (CAD), revealing a non-negligible prevalence of subclinical atheroma even in asymptomatic athletes. OBJECTIVE: To examine the evolving role of coronary computed tomography angiography (CCTA) in the primary prevention of IHD in master athletes, with a focus on risk stratification, plaque characterization, and integration into sports eligibility assessment. CONTENT: Technological advances have enhanced the diagnostic performance of CCTA, allowing not only the detection of obstructive disease but also the identification of high-risk plaque features, such as low-attenuation fibro-lipid core, positive remodelling, and microcalcifications. In selected older athletes with elevated risk profiles or equivocal stress tests, CCTA provides valuable anatomical information that often eludes functional testing alone. Italian guidelines (COCIS 2023) include CCTA in the evaluation of intermediate-to-high-risk master athletes, emphasizing a risk-adapted approach rather than blanket screening. CONCLUSIONS: CCTA may refine cardiovascular risk assessment in master athletes by detecting subclinical but clinically relevant CAD, potentially improving long-term outcomes and guiding individualized recommendations for sports participation. While broader implementation must consider cost, radiation exposure, and the risk of overdiagnosis, selective use of CCTA appears justified in targeted high-risk populations. Prospective studies are needed to validate this strategy and define its role within comprehensive athlete evaluation frameworks.