Coronary artery calcium in athletes: friend or foe?

Regular physical activity and high cardiorespiratory fitness protect against cardiovascular disease-related morbidity and mortality and all-cause mortality in the general population. Paradoxically, recent evidence indicates that high volumes of aerobic physical activity are associated with an increased prevalence and progression of coronary artery calcium and coronary plaques in males. This review aims to synthesize current evidence concerning the relationship between aerobic physical activity and the development of coronary atherosclerosis. Evidence indicates that engaging in moderate-to-vigorous physical activity, exceeding approximately five hours or 2000 Metabolic Equivalent of Task-mins per week, is associated with increased prevalence and progression of coronary artery calcium and coronary plaques in males. This relationship appears intensity-dependent, with higher-intensity physical activity linked to greater progression of coronary artery calcium and coronary plaques. However, females seem to be less susceptible to physical activity-associated coronary atherosclerosis. Recent findings challenge the hypothesis that increased coronary artery calcification in athletes represents plaque stabilization. Athletes with elevated coronary artery calcium levels show an increased risk of cardiovascular disease outcomes and all-cause mortality compared to those without coronary artery calcium. However, their typically higher levels of cardiorespiratory fitness and physical activity, partially mitigate this risk, particularly for all-cause mortality. For optimal cardiovascular health, evidence supports maintaining physical activity volumes aligned with World Health Organization guidelines and emphasizing moderate-intensity activity (in relative terms), as this pattern appears to protect against coronary atherosclerosis development and is associated with reduced coronary artery calcium progression and lower prevalence of mixed plaques in males.