Extreme endurance training and coronary artery disease: A systematic review and a meta-analysis

Background: Physical activity is advocated for cardiovascular health; however, excessive endurance exercise may pose risks. This systematic review and meta-analysis explore the relationship between endurance training and coronary artery disease (CAD) diagnosed at coronary CT angiography (CCTA). Methods: Following PRISMA guidelines, we searched MEDLINE, Embase, and Scopus up to January 4th, 2024. Inclusion criteria encompassed studies on adults with sample size >10, various study designs, and assessment of endurance training and CAD via CCTA. Results: Endurance athletes exhibited a higher prevalence of coronary atherosclerosis compared to controls. However, they did not demonstrate a greater prevalence of high-risk or obstructive plaques. Continuous coronary artery calcium (CAC) scores did not significantly differ between athletes and controls. Athletes showed a slight increase in the odds of having CAC > 400. Conclusion: Endurance athletes are more likely to have coronary atherosclerosis but not more likely to have high-risk plaques compared to sedentary individuals. Further research is needed to establish threshold values for physical exercise beyond which sports can become harmful and identify which types of sports carry the greatest risk.