Coronary Atherosclerosis in Master Athletes: Current Knowledge and Future Challenges

Coronary atherosclerosis in master athletes represents a paradox: despite the well-established cardiovascular benefits of regular exercise, highly trained endurance athletes show a higher prevalence of coronary plaques than their non-athletic peers. The mechanisms behind this finding are multifactorial, involving sustained high shear stress on the vascular wall, exercise-induced inflammatory activation, altered calcium homeostasis, and interactions between genetic predisposition and sport-specific lifestyle factors. Although athletes tend to exhibit predominantly calcified—potentially more stable—plaques, recent studies highlight that mixed and non-calcified lesions are also present, particularly among lifelong endurance athletes, raising questions about their true long-term risk. Clinically, traditional risk scores often underestimate risk in this population, making multimodal assessment with tools such as coronary calcium scoring and coronary CT angiography essential. This review synthesizes the current knowledge on mechanisms, clinical implications, diagnostic strategies, and prevention of coronary atherosclerosis in athletes, while underscoring key gaps that future research must address.