Resilience against exercise-related coronary atherosclerosis: A case study in a master athlete participating in 500 marathons

Abstract

Background and purpose: Lifelong endurance exercise is generally associated with cardiovascular health benefits. However, recent studies suggest that prolonged high-volume training may contribute to coronary atherosclerosis, even in athletes with low traditional cardiovascular risk. This case report aims to explore the cardiovascular status of a master endurance athlete with an exceptionally high lifetime training volume, in light of recent concerns raised in the literature.

Methods: We present the case of a 60-year-old recreational male marathon runner with no history of cardiovascular disease, who completed over 500 marathons between the ages of 30 and 60 years, covering ~127 000-km running. In 2024 alone, he completed 60 marathons. Cardiovascular evaluation included clinical risk assessment and coronary computed tomography angiography (CTCA).

Results: The runner was asymptomatic, had a low ESC-SCORE2 (3.3%), a favorable lipid profile, and normal levels of high-sensitivity C-reactive protein and lipoprotein (a). CTCA revealed no evidence of calcified, mixed, or non-calcified coronary plaques.

Conclusions: This case highlights that some master athletes may demonstrate resilience to coronary atherosclerosis despite decades of high training volume. In low-risk individuals, prolonged endurance training alone may not necessarily lead to coronary artery disease, emphasizing the need for individualized cardiovascular screening strategies.

Keywords

Running / Middle-aged man / Cardiovascular disease

CRediT authorship contribution statement

Beat Knechtle: Writing - original draft, Conceptualization. Sasa Duric: Writing - review & editing, Formal analysis. Volker Scheer: Writing - review & editing. Pantelis T. Nikolaidis: Writing - review & editing. Daniela Chlíbková: Writing - review & editing. Luciano Bernardes Leite: Writing - review & editing. Ivan Cuk: Writing - re-view & editing. Pedro Forte: Writing - review & editing. Matthias Wilhelm: Writing - review & editing. Katja Weiss: Writing - review & editing. Thomas Rosemann: Writing - review & editing.

Ethics approval and consent to participate

The athlete gave his informed written consent to use all his publicly available data provided on his website. The study was approved by Ethikkommission des Kantons St. Gallen (1-6-2010). The study was implemented in accordance with the Declaration of Helsinki.

Declaration of competing interest

Beat Knechtle is an Editorial Board Member for Sports Medicine and Health Science and was not involved in the editorial review or the de-cision to publish this article. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

We thank the runner for providing us all his specific data.

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