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REVIEW ARTICLE • Fisioter. Mov. 38 • 2025 • https://doi.org/10.1590/fm.2025.38206 linkcopy

Cardiovascular health in master athletes engaged in competitive sport

Esporte competitivo e saúde cardiovascular de atletas master

Authorship SCIMAGO INSTITUTIONS RANKINGS

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failed to identify the sport involved, were not available in full, or were letters to editors, commentaries, or unpublished manuscripts.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

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.

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

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

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