Cardiovascular health in master athletes engaged in competitive sport

Esporte competitivo e saúde cardiovascular de atletas master

Abstract

Introduction  Aging is naturally accompanied by a de-cline in overall health. Regular physical activity, whether amateur or competitive, is recognized as a key strategy to promote health and well-being in older adults. However, many individuals begin exercising without prior cardio-vascular assessment.

Objective  This systematic review aimed to assess the prevalence and types of cardiovas-cular diseases in master athletes.

Methods  Observational studies published within the last ten years were included if they evaluated cardiovascular outcomes or diseases in master athletes (aged >35 years) participating in any sport. Studies were excluded if they lacked data on pre-defined cardiovascular outcomes, focused solely on re-habilitation or training interventions, failed to identify the sport involved, were not available in full, or were letters to editors, commentaries, or unpublished manuscripts. The literature search strategy used the following key-words: “cardiovascular outcomes,” “cardiac outcomes,” “cardiovascular diseases,” “cardiac outcomes” and “master athletes.” Results: Ten studies were included, most in-volving master endurance athletes aged 35 to 90 years. Seven studies included both sexes, two included only men, and one did not specify sex. Reported outcomes included atrial fibrillation (n = 2), arrhythmia (n = 2), myo-cardial fibrosis (n = 1), ventricular dysfunction (n = 1), and atherosclerotic disease (n = 5). Of the ten studies, eight reported that master athletes have a higher propensity to develop cardiovascular disease, while two found no such association.

Conclusion  Master athletes may face an increased risk of cardiovascular disease. These find-ings highlight the importance of thorough cardiovascular screening before engaging in competitive sports at older ages.

Keywords
Cardiovascular diseases; Physical activity; Aging

Resumo

Introdução  O envelhecimento é associado ao declínio da saú-de. A atividade física e a prática de esporte amador ou competi-tivo vêm com o intuito de agregar na saúde destes indivíduos, porém muitos iniciam a atividade física sem conhecimento pré-vio de sua condição cardiovascular.

Objetivo  Compreender as doenças cardiovasculares em atletas master.

Métodos  Trata-se de uma revisão sistemática de estudos observacionais que investigaram desfechos/doenças cardiovasculares em atletas master (acima de 35 anos), praticantes de qualquer modalidade esportiva nos últimos dez anos. Foram excluídos estudos que não destacaram os desfechos-alvos do trabalho, que abran-geram reabilitações ou treinamentos, que não delimitaram os esportes praticados, cartas ao revisor ou comentários, manus-critos não publicados e aqueles não disponíveis na íntegra. As palavras-chave de busca foram “cardiovascular outcomes” ou “cardiac outcomes” ou “cardiovascular diseases” ou “cardiac outcomes” e “master athletes”.

Resultados  Foram avaliados dez estudos, com predominância de atletas master de endu-rance com idade entre 35 e 90 anos. Sete estudos avaliaram homens e mulheres, dois estudos avaliaram somente homens e um estudo não mencionou a informação. Quanto aos desfe-chos, os resultados incluíram fibrilação atrial (n = 2), arritmias (n = 2), fibrose miocárdica (n = 1), disfunção ventricular (n = 1) e doenças ateroscleróticas (n = 5). Dos dez artigos avaliados, somente dois não identificaram maior risco cardiovascular em atletas master. Os demais estudos apontaram que atletas mas ter têm maior propensão a desenvolver doenças cardiovas-culares.

Conclusão  Esta revisão traz indícios de que atletas master apresentam risco cardiovascular, sendo necessária, por-tanto, a triagem detalhada sobre condições cardiovasculares anteriormente à prática esportiva.

Palavras-chave
Doenças cardiovasculares; Atividade física; Envelhecimento

Introduction

Aging is typically characterized by a progressive phy-siological decline that compromises functional capacity, independence, and quality of life. It increases suscepti-bility to chronic diseases, promotes sarcopenia, and leads to greater reliance on healthcare services.¹ Even in the absence of diagnosed conditions such as systemic arterial hypertension (SAH) or cardiovascular diseases (CVD), structural and functional changes occur in the cardiovas-cular system over time, ultimately compromising cardiac reserve. These age-related changes lower the threshold for the development of three key cardiac conditions: ventricular hypertrophy, chronic heart failure (CHF), and atrial fibrillation (AF), all of which become more preva-lent with advancing age. Cardiac aging also involves myocyte loss, compensatory hypertrophy, and reduced responsiveness to sympathetic stimuli, which together impair myocardial contractility and cardiac output.²

Another hallmark of aging is oxidative stress, dri-ven by an imbalance between oxidant and antioxidant compounds that favors the excessive production of free radicals. Prolonged oxidative stress is implicated in the etiology of numerous conditions, such as atheroscle-rosis, diabetes mellitus, obesity, neurodegenerative di-sorders, cancer, and cardiovascular disorders.³ Studies indicate that this phenomenon is also associated with aging.⁴,⁵

Despite these physiological declines, master athle-tes defy the stereotypes of frailty and functional decline often associated with aging. The prevalence of chro-nic diseases or disabilities is significantly lower among this population, even in individuals aged 70 years and older.⁶

The age at which an athlete is considered a “master” or “veteran” varies by sport: from 25 years old in swim-ming⁷ and 35 years in athletics.⁸ Notably, cardiovascu-lar problems tend to become a major cause of morbi-dity from the age of 35 onwards.¹⁰,¹¹ Master athletes are typically defined as individuals engaged in competitive individual or team sports that emphasize performance and involve regular, structured training. Master sports enable older individuals to regularly compete against others in the same age category across a wide variety of disciplines. Competitions range from local monthly events to large-scale national and international cham-pionships held every two to four years.¹²

Events organized and marketed exclusively for mas-ter athletes have increased in number and popularity in recent years.¹³ The master athlete population is highly heterogeneous, including former professionals who have maintained long-term training regimens, as well as pre-viously sedentary individuals who adopt competitive exercise later in life — sometimes abruptly.¹⁴

Regular moderate physical activity is well established as a protective factor against all-cause mortality and a promoter of long-term cardiovascular health.¹⁵ Current guidelines recommend 150 minutes of moderate or 75 minutes of vigorous aerobic activity per week for adults to achieve substantial health benefits,¹⁶ including those with chronic conditions such as type 2 diabetes melli- tus and SAH (150–300 minutes of moderate or 75–150 minutes of vigorous exercise per week). Additional benefits are also gained from muscle-strengthening exer-cises performed at least two to three times a week.¹⁷

However, the well-known and documented cardio-vascular benefits of physical exercise must be weighed against its potential risks, particularly in athletes overthe age of 35 – 40 years.¹⁵ These individuals have a high risk of sport-related acute cardiovascular events, including sudden death (SD), primarily due to under-lying atherosclerotic coronary artery disease (CAD).¹⁸ Furthermore, approximately 50% of patients who expe-rience acute myocardial infarction (AMI) or sudden car-diac arrest have no prior symptoms or known history of CAD.¹⁶

Recently, concerns regarding the potential cardio-vascular risks of excessive endurance exercise have re-cently gained considerable attention from the media and scientific community. Endurance sports, defined by sustained aerobic effort, have been linked to early-onset AF, increased coronary artery calcification (CAC), and unexplained myocardial fibrosis.¹⁶

Thus, to ensure safe participation in competitive sports that demand high exertion, identifying individuals at risk is essential.¹⁹ Several risk stratification algo-rithms have been developed for this purpose. Current recommendations for pre-participation cardiovascular assessment in adults incorporate traditional risk factors such as age, sex, blood pressure, cholesterol levels, and smoking history,¹⁸ as well as self-reported questionnaires and diagnostic tools including resting and exer-cise electrocardiograms (ECGs). Notably, European and American guidelines differ on several points. However, some authors argue that large-scale screening of mas-ter athletes is not warranted, even for high-intensity en-durance events such as marathons.¹⁵

According to Abbatemarco et al.,²⁰ in the United States, only 24.6 – 51.5% of novice endurance runners (less than five years of training) undergo pre-participation screening. This is partly due to healthcare profes-sionals referring athletes for screening only when they are older or competing in long-distance events, often neglecting established cardiovascular risk factors such as SAH, DM, hypercholesterolemia, smoking, and family history.

This has contributed to a widespread belief that athletes are relatively “immune” to cardiovascular disease. However, there is an undeniable risk of adverse out-comes such as AMI, SD, and AF, particularly in asymp-tomatic individuals with a relevant family history. Thus, a clear knowledge gap remains in understanding the cardiovascular risks faced by master athletes. As such, this study aimed to conduct a systematic review of the literature to investigate cardiovascular diseases (e.g., atherosclerosis, arrhythmias, CHF) and related outcomes (e.g., AMI, SD, ventricular dysfunction) in master athletes.

Methods

This systematic review was conducted in accordan-ce with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines²¹ and was registered in the PROSPERO database (registration number: CRD42024543042).

Search strategy

One researcher conducted the database search and exported the results into StArt software, which consoli-dates search results from multiple databases, identifies duplicates, and facilitates study selection and data extraction.²²

Searches were performed in the PubMed, LILACS, SciELO, MEDLINE, Web of Science, and Cochrane da-tabases via the CAPES Journals Portal (Figure 1). Keywords were selected based on relevant literature and the Medical Subject Headings (MeSH) thesaurus, using the following terms: “cardiovascular outcomes” OR “cardiac outcomes” OR “cardiovascular diseases” OR “cardiac diseases” AND “master athletes.” To identify addi-tional studies, the reference lists of included articles were also manually screened. No restrictions were pla-ced on language or access type (open or paid).

Figure 1
Flowchart of publication selection according to inclusion criteria.

Two independent researchers screened the titles, abstracts, and keywords of all the studies identified. Potentially eligible articles were retrieved in full for fur-ther assessment and possible inclusion in the systematic review. Disagreements were resolved through discus-sion with a third researcher.

Inclusion and exclusion criteria

Studies were eligible if they were observational, prospective, and retrospective research that investiga-ted cardiovascular diseases and their outcomes in mas-ter athletes (aged > 35 years), engaged in any type of sport. The cardiovascular diseases of interest were atherosclerosis, arrhythmias, and CHF. Outcomes included

AMI, SD, and ventricular dysfunction. Only studies publi-shed in the past ten years (2014–2024) were included, reflecting the growing interest in performance-related cardiovascular issues in this population in the last decade.

Exclusion criteria were studies that did not report the diseases or outcomes of interest, those focused on rehabilitation or training, that did not specify the sport practiced, and were not available in full. Letters to the editor, commentaries, systematic reviews, meta-analy-ses, case reports, and unpublished manuscripts were also excluded.

Data extraction and quality assessment

Data extraction was performed independently by two researchers and compiled into an Excel spread-sheet. The following information was extracted from each study: title, authors, year of publication, country, study design, type of sport, sample characteristics (sex and age), cardiovascular diseases/outcomes, and diag-nostic instruments or examinations used (Table 1).

Table 1
Abstracts of articles included in the study

Studies	Title	Sport studied	Population	Results
Myrstad et al.28 2014, Norway Study design: cross-sectional	Increased risk of atrial fibrillation among elderly Norwegian men with a history of long-term endurance sport practice	Cross-country skiing	509 athletes who participated in ski racing in years prior to the survey, and 1867 controls; 65-90 years old	The estimated risk of AF in sedentary individuals was 11.3%. The estimated risk of AF for participants engaging in moderate physical activity was 13.0% and 17.6% for intense physical activity.
Abdullah et al.38 2016, USA Study design: cross-sectional	Lifelong physical activity regardless of dose is not associated with myocardial fibrosis	Participants in competitions organized by the US Masters Sports Associations (marathons and triathlons)	92 men and women (4 groups: sedentary; occasional PA practitioners; regular PA practitioners; competitive athletes); > 65 years old	Left ventricular end-diastolic volume, end-systolic volume, and mass were higher in those with a history of higher physical activity levels. No difference in ejection fraction. No intergroup difference in late gadolinium enhancement (indicating no evidence of myocardial fibrosis in the participants).
Shapero et al.31 2016, USA Study design: cross-sectional	Cardiovascular risk and disease among masters endurance athletes: insights from the Boston MASTER (Masters Athletes Survey To Evaluate Risk) initiative	Boston Marathon Runners	591 athletes (391 men and 200 women); > 35 years old	64% of athletes had one or more Cardiovascular risk factors; 9% prevalence of established cardiovascular disease; AF was associated with years of exposure to exercise; CAD was associated with dyslipidemia; CAD was not associated with exposure to exercise.
Merghani et al.30 2017, UK Study design: cross-sectional	Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile	Running and cycling	152 athletes (70% men), and 92 controls; > 40 years old	Most athletes (60%) and control subjects (63%) had normal CAC scores. Number of years of training was the only independent variable associated with a higher risk of CAC. Male athletes were more likely to have coronary plaques compared with sedentary men with a similar.
Morrison et al.19 2018, Canada Study design: cross-sectional	Assessment of cardiovascular risk and preparticipation screening protocols in masters athletes: the Masters Athlete Screening Study (MASS): a cross sectional study	23 disciplines, primarily running, cycling, hockey, triathlon and rowing	798 athletes (500 men and 298 women); > 35 years old	Cardiovascular disease was detected in 11.4%, with CAD (7.9%) being the most common diagnosis. A high Framingham risk score (>20%) was observed in 8.5% of the study population. Ten athletes were diagnosed with significant CAD; 90% were asymptomatic. A high Framingham risk score was the strongest indicator of underlying CAD.
Panhuyzen-Goedkoop et al.32 2020, Netherlands Study design: retrospective study	ECG criteria for the detection of high-risk cardiovascular conditions in master athletes	Athletes linked to the Dutch Olympic Committee	2578 athletes; > 35 years old	Atrial enlargement (n = 109; 4.1%) and left ventricular hypertrophy (n = 98; 3.8%) were the most common abnormalities identified using the ESC-2005 or Seattle criteria. ST-segment deviation (n = 66; 2.6%) and T-wave inversion (n = 58; 2.2%) were the most frequent findings based on the International criteria. The ESC-2005 criteria detected a larger number of exercise-related heart conditions (n = 46; 1.8%) compared with the Seattle (n = 36; 1.4%) and International criteria (n = 33; 1.3%). Coronary artery disease was the most frequently identified high-risk cardiovascular condition (n = 24; 0.9%).
Cavigli et al.34 2020, Italy Study design: cross-sectional	The acute effects of an ultramarathon on biventricular function and ventricular arrhythmias in master athletes	Ultramarathon	68 athletes (47% men); > 40 years old	Increased R wave amplitude in V1 and prolonged QTc interval following the ultramarathon. 7% of athletes exhibited isolated exercise-induced premature ventricular beats. No episodes of nonsustained ventricular tachycardia or changes in left ventricular ejection fraction, global longitudinal deformation, or torsion were observed.
German et al. 29 2020, USA Study design: prospective cohort	Physical activity, coronary artery calcium, and cardiovascular outcomes in the Multi-Ethnic Study of Atherosclerosis (MESA)	Physical activity	6777 men and women; 45 to 84 years old	Participants at low risk for CAC in the highest PA quartile had reduced adjusted hazard ratios for CVD and all-cause mortality compared to those in the lowest PA quartile. Participants at high risk for CAC in the highest PA quartile also had reduced adjusted hazard ratios for all-cause mortality compared to those in the lowest PA quartile. High PA was not associated with an increased risk of any outcomes, regardless of CAC category, sex, or race/ethnicity.
Gao et al.35 2020, China Study design: prospective cohort	Associations of long-term physical activity trajectories with coronary artery calcium progression and cardiovascular disease events: results from the CARDIA study	Physical activity	2497 (1120 men and 1377 women); 40.4 ± 3.6 years old	The High PA group had a greater risk of CAC progression compared to the low PA group after adjusting for traditional cardiovascular risk factors. High PA was not associated with an increased risk of incident cardiovascular events, and the incidence of cardiovascular events among participants with CAC progression was similar across all physical activity levels.
Bosscher et al.36 2023, Belgium Study design: prospective cohort	Lifelong endurance exercise and its relation with coronary atherosclerosis	Running, cycling, triathlon	176 controls, 191 late athletes, and 191 lifelong athletes; Men; 40 to 70 years old	Prevalence of coronary plaques (calcified, mixed, and non-calcified). The athlete group demonstrated higher peak oxygen consumption. Lifetime endurance sports participation was associated with greater odds of having ≥1 coronary plaque (OR: 1.86, CI: 1.17–2.94), ≥1 proximal plaque (OR: 1.96, CI: 1.24–3.11), ≥1 calcified plaque (OR: 1.58, CI: 1.01–2.49), ≥1 proximal calcified plaque (OR: 2.07, CI: 1.28–3.35), ≥1 non-calcified plaque (OR: 1.95, CI: 1.12–3.40), ≥1 proximal non-calcified plaque (OR: 2.80, CI: 1.39–5.65), and ≥1 mixed plaque (OR: 1.78, CI: 1.06–2.99) compared to healthy non-athletes.

• Note: AF = atrial fibrillation; CAC = coronary artery calcification; CAD = coronary artery disease; PA = physical activity.
• Note: CAC = coronary artery calcification; CARDIA = Coronary Artery Disease Risk Development in Young Adults; CI = confidence interval; CVD = cardiovascular disease; ECG = electrocardiogram; ESC = European Society of Cardiology; OR = odds ratios; PA = physical activity; QTc = corrected QT interval (ECG); R = R wave (ECG); ST = segment between the end of the QRS complex and the beginning of the T wave (ECG); V1 = ECG lead V1.

The methodological quality of the included studies was assessed using checklists by the Joanna Briggs Institute for cross-sectional²³ and cohort.²⁴ Two inde-pendent researchers conducted the assessments and disagreements were resolved through discussions with the research team. The checklists for cross-sectional stu-dies and for cohort studies contain eight and eleven items, respectively. Each item was scored as “yes,” “no,” “unclear,” or “not applicable.” Methodological quality was rated as low (≤ 4 “yes” responses), moderate (5–6), and high (≥ 7) for cross-sectional studies; and low (≤ 5 “yes” responses), moderate (6–9), and high (≥ 10) for cohort studies.

Results

The literature search was conducted between Fe-bruary and April 2024, and initially identified 208 pu-blications across the online databases. After removing 74 duplicates, 134 records remained for screening. Ba-sed on titles and abstracts, 120 studies were excluded for not meeting the scope of the review. Of the 14 ar-ticles that met the inclusion criteria, two were excluded because the full text was not available and two for being literature reviews. Thus, ten studies were included in the final systematic review.

The ten studies included in this review represented a wide range of sports disciplines, with endurance sports being the most common among master athletes. Study designs comprised six cross-sectional, one retrospective, and three prospective cohort studies. Sample sizes va-ried considerably, with cohort studies involving a total of over 9,000 individuals and crosssectional assessing 68 to 798 participants. The retrospective study analyzed data from 2,578 individuals, and the prospective cohort 392 participants. Participants’ ages ranged from 35 to 90 years across all studies. Seven studies included both men and women, two focused exclusively on men, and one did not report the sex of the participants. In terms of cardiovascular outcomes, AF was examined in two studies, arrhythmias in two, myocardial fibrosis in one, ventricular dysfunction in one, and atherosclerotic di-seases in five (Table 1).

The methodological quality of the included studies was assessed using the JBI checklists for cross-sectional and cohort studies. As shown in Tables 2 and 3, cross-sectional study scores ranged from 4 to 7, with an average of 6, and cohort studies from 6 to 9 with an aver-age score of 7. No study was classified as having low methodological quality.

Table 2
Methodological quality of the cross-sectional studies included in the review

Study	1.	2.	3.	4.	5.	6.	7.	8.	9.
Myrstad et al.28	Yes	Yes	No	No	No	No	Yes	Yes	4/8
Abdullah et al.38	Yes	Yes	Yes	Yes	No	No	Yes	Yes	6/8
Shapero et al.31	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	7/8
Merghani et al.30	Yes	Yes	Yes	Yes	No	No	Yes	Yes	6/8
Morrison et al.19	Yes	Yes	No	Yes	Yes	Yes	No	Yes	6/8
Panhuyzen-Goedkoop, et al.32	No	No	Yes	Yes	Yes	Yes	Yes	Yes	6/8
Cavigli et al.34	Yes	Yes	No	Yes	No	No	Yes	Yes	5/8

• Note: 1. Were the inclusion criteria for the sample clearly defined? 2. Were the study subjects and setting described in detail? 3. Was the exposure measured validly and reliably? 4. Were objective and standardized criteria used for measuring the condition? 5. Were confounders identified? 6. Were strategies for dealing with confounders stated? 7. Were the outcomes measured validly and reliably? 8. Was appropriate statistical analysis used? 9. Quality.

Table 3
Methodological quality of the cohort studies included in the review

Study	1.	2.	3.	4.	5.	6.	7.	8.	9.	10.	11.	12.
German et al. 29	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	No	Yes	9/11
Gao et al. 35	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	No	No	Yes	8/11
Bosscher et al.36	No	No	Yes	Yes	Yes	Yes	Yes	N/A	N/A	N/A	Yes	6/11

• Note: 1. Were the two groups similar and recruited from the same population? 2. Were exposures measured similarly to assign people to the exposed and unexposed groups? 3. Was exposure measured validly and reliably? 4. Were confounders identified? 5. Were strategies to address confounders stated? 6. Were groups/participants free of the outcome at baseline (or at time of exposure)? 7. Were outcomes measured validly and reliably? 8. Was follow-up time reported and sufficient for outcomes to occur? 9. Was follow-up complete and, if not, were reasons for loss to follow-up described and explored? 10. Were strategies used to address incomplete follow-up? 11. Was appropriate statistical analysis used? 12. Quality. N/A = not applicable.

Discussion

This systematic review aimed to identify the presen-ce of cardiovascular diseases and related outcomes in master athletes. There is robust evidence linking regugular physical activity with health promotion, providing both physiological and psychological benefits.²⁵ However, Brazilian literature lacks studies specifically examining cardiovascular diseases and outcomes in mas-ter athletes, a gap made more significant by two recent social trends: an aging population and the increasing “sportification” of this population — on identifying this group.²⁶ To address this, we reviewed the current lite-rature on the topic. Of the ten studies analyzed, only two did not report increased cardiovascular risk among master athletes, whereas the majority indicated that this population is more susceptible to cardiovascular diseases.²⁷

The Brazilian Guideline on Sports and Exercise Cardi-ology²⁷ recommends a thorough pre-participation cardiovascular assessment for individuals engaging in sports, aiming to identify risk factors and cardiovascular con-ditions that may contraindicate exercise or predispose to SD. This evaluation typically includes clinical history, physical examination, and screening questionnaires, supplemented by blood work, ECGs, stress tests, cardio-pulmonary exercise testing, and echocardiography.

Within our review, two studies assessed cardiovas-cular outcomes exclusively through questionnaires;²⁸,²⁹ two¹⁹,³⁰ combined questionnaires with complementary exams; and the remainder relied primarily on diagnostic exams. ECG was the most commonly used tool, fol-lowed by magnetic resonance imaging and computed tomography.

Several studies focused on cardiac rhythm abnorma-lities in master athletes. For example, Myrstad et al.²⁸ reported an increased risk of AF in athletes over 65 years old with a history of competitive cross-country ski-ing. AF was identified through questionnaires, and re-sults showed that the estimated risk of AF was higher among participants engaging in moderate or vigorous physical activity compared to sedentary individuals. Similarly, Shapero et al.,³¹ observed an association be-tween AF and cumulative years of physical exercise, with a 9% prevalence of established CVD in master athletes.

Panhuyzen-Goedkoop et al.³² evaluated the appli-cability to master athletes of ECG interpretation criteria developed for younger athletes (<35 years). Despite the elevated risk of master athletes relative to the general population, it remains unclear whether these traditional criteria adequately identify high-risk cardiovascular con-ditions in the older athletic population.

These findings contrast with the review by Fyyaz et al.,³³ who argued that exercise-induced arrhythmias are rare and predominantly occur in athletes with genetic predisposition. Reinforcing this notion, Cavigli et al.³⁴ studied 68 ultramarathon master athletes and found no evidence of exercise-induced ventricular dysfunction or significant acute arrhythmias. However, the study’s limi-tations included data collected only before and after the race, absence of 12-lead ECGs, and the homogeneous Caucasian sample, restricting generalizability to other ethnic groups.

With respect to obstructive heart disease, Merghani et al.³⁰ evaluated subclinical CAD in endurance master athletes with low atherosclerotic risk profiles. While most participants had normal CAC scores, a longer history of endurance training independently correlated with hig-her CAC risk. The authors suggested that although this might indicate a negative effect of long-term endurance training, the calcified and stable nature of these plaques could offer protection against rupture and myocardial infarction.³⁰

Morrison et al.¹⁹ studied cardiovascular risk assess-ment during pre-participation screening in master ath-letes and emphasized that these individuals are not im-mune to cardiovascular risk or disease. In their sample of 798 athletes, 11.4% had diagnosed cardiovascular disease, with CAD being the most prevalent.

German et al.²⁹ and Gao et al.³⁵ explored the re-lationship between physical activity and cardiovascular health in two longitudinal multicenter studies, namely Multi-Ethnic Study of Atherosclerosis (MESA) and Coronary Artery Disease Risk Development in Young Adults (CARDIA), respectively. The former evaluated the asso-ciation between physical activity levels (high, moderate, low) and the presence of CAC as a predictor of future cardiovascular events, and the latter investigated the long-term impact of physical activity trajectories on CAC progression and cardiovascular risk events. Both studies used CAC as a marker of cardiovascular risk. Specifically, MESA focused on the impact of current physical activity levels on CAC presence, while CARDIA followed individuals with a mean age of 40.4 ± 3.6 years to examine how the evolution of physical activity throughout life influences cardiovascular risk.

Both studies found that higher physical activity le-vels were not associated with an increased risk of CAC or cardiovascular events, with MESA²⁹ emphasizing the cardiovascular benefits of physical activity and the CARDIA study³⁵ indicating a similar incidence of car-diovascular events even among participants with CAC progression across all physical activity levels. Together, these studies offer a broader perspective on the rela-tionship between physical activity and cardiovascular health. However, it is important to note that neither stu-dy specifically examined master athletes.²⁹,³⁵

Bosscher et al.³⁶ reported a paradoxical association between lifelong endurance exercise and coronary atherosclerosis, challenging the long-standing belief that re-gular exercise protects against heart disease. Lifelong endurance athletes exhibited a higher prevalence of coronary plaques — including those more prone to rupture and acute cardiac events — compared to physically active non-athletes. Although the study did not evaluate the incidence of cardiovascular events such as myo-cardial infarction or stroke, the presence of coronary plaques is a known predictor of these outcomes. These findings suggest that lifelong endurance athletes may have a higher-than-expected risk for serious cardiovascular events. However, Aengevaeren et al.³⁷ repor-ted more stable coronary plaque profiles in endurance athletes, with a predominance of calcified plaques less prone to rupture, indicating a potentially lower risk of major cardiovascular events in this population.

With regard to cardiac structure, Abdullah et al.³⁸ found no evidence of myocardial fibrosis in a sample di-vided into four groups (sedentary, occasional exercisers, regular exercisers, and competitive athletes). Among regular competitors, corresponding to the master athle-tes of interest in our review, no adverse cardiac out-comes were observed. However, interpretation of these findings is limited by the small sample size of master athletes and the study’s inability to account for variables such as exercise intensity, duration, or modality.³⁸

An important consideration in studies involving mas-ter athletes is the distinction between individuals with a lifelong history of sports participation and those who began exercising later in life. Many studies included in this review were cross-sectional and therefore did not assess long-term exposure to physical activity. This omission may overlook morphofunctional cardiac adapta-tions that develop over time and could contribute to arrhythmias, reduced contractile capacity, or structural responses to ischemic events.

Moreover, the long-held belief that regular endu-rance exercise protects against ischemic heart disease has been increasingly questioned. Recent studies report a greater prevalence of coronary disease and atheros-sclerotic plaque formation among highly trained athletes compared to healthy non-athletes.³⁶These find-ings do not support the hypothesis that highly trained endurance athletes develop more benign plaque com-positions that explain their lower cardiovascular event rates. Therefore, physical exercise should not be viewed as the sole determinant of favorable cardiovas-cular outcomes but rather should be integrated a broa-der framework of healthy lifestyle practices, including balanced nutrition, moderate alcohol consumption, and smoking cessation.

Similarly, Fruytier et al.³⁹ reported cases of asympto-matic master athletes who experienced adverse events during sports participation. It is well established that most sports-related deaths occur among athletes over 35 years old. While sudden cardiac events in younger athletes are typically caused by congenital, structural, or electrical cardiac disorders, CAD is the leading cause of major cardiovascular events in master athletes. As such, pre-participation assessment is essential to define clear criteria and protocols that ensure safe sports par-ticipation in this population. Event organizers should also verify that all participants, especially those over 35, are medically cleared to take part.

Our methodological assessment identified key limi-tations in the included studies. In the cross-sectional studies, exposure was not always measured validly or reliably, and confounding factors were not consistently addressed. In cohort studies, important aspects such as loss to follow-up and strategies for handling incomple-te data were often insufficiently reported. These short-comings should be addressed in future studies.

This review also has limitations. The number of stu-dies included was small. Heterogeneity across samples, including differences in age, physical activity level, type of exercise, assessment instruments, and sex distribution, precluded the performance of meta-analysis, which would have strengthened the external validity of our findings. Moreover, no studies evaluated Brazilian master athletes, underscoring the need for local re-search to investigate their specific characteristics and challenges, such as healthcare access and pre-parti-cipation screening. Additionally, while several studies demonstrated methodological weaknesses that limited their quality ratings, most attempted to minimize bias.

Despite these limitations, this review provides im-portant insights into cardiovascular risk and outcomes in master athletes and underscores the value of systematic health evaluation and monitoring by professionals.

Conclusion

This review provides evidence that master athletes may face increased risk for cardiovascular disease. As such, these findings reinforce the need for compre-hensive cardiovascular screening before participation in recreational or competitive sports. This preventive approach may help reduce the incidence of sudden cardiac death and guide healthcare providers and high-performance trainers and coaches in safely managing this population.

Acknowledgments

This study was funded by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Funding Code 001, and Fundação de Amparo à Pesquisa do Estado de São Paulo (# 2024/13114-9).

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Publication Dates

• Publication in this collection
  15 Sept 2025
• Date of issue
  2025

History

• Received
  19 June 2024
• Received
  27 Mar 2025
• Accepted
  23 June 2025