▎WuXi AppTec content team editor
Early studies suggest that regular endurance exercise can relatively increase immune tolerance to ischemic cardiomyopathy. Regular exercise can help improve blood pressure, blood lipid levels, reduce the incidence of diseases such as diabetes and myocardial infarction, increase life expectancy, and reduce the occurrence of cardiovascular events. However, recent studies have found that the prevalence of coronary atherosclerotic plaque in well-trained exercisers has increased compared to healthy non-exercisers.
The 2023 American College of Cardiology (ACC) Clinical Research III released a study on the relationship between lifelong endurance exercise and coronary atherosclerosis, confirming that long-term endurance exercise is not related to the nature of coronary plaque composition (i.e., stable plaque and unstable plaque). Long-term endurance training exercisers have more coronary plaque than non-exercisers at lower risk of cardiovascular events, and more longitudinal studies are needed to support this. The findings were published in the European Heart Journal at the same time.
Screenshot credit: European Heart Journal
Study design
The study ultimately included 605 male subjects aged 45~70 years (women had a lower risk of coronary artery disease and were therefore not included), all from the Athlete Heart Master (Master@Heart) research program, a multicenter prospective cohort study in which researchers recruited and screened participants through a specific portal.
Exercisers: Questionnaires reported 8 hours ≥of cycling per week, or 6 hours of running ≥ per week, or 8 hours of triathlon (swimming, cycling, and running≥) per week, for 6 months or more prior to baseline. Among them< those who started regular endurance exercise at the age of 30 and >30 years were defined as long-term athletes and late-stage exercisers, respectively.
Non-active participants: ≤ 3 hours of physical activity per week, and no regular endurance exercise prior to trial participation.
Observe the metrics
Studies hypothesize that more long-term endurance exercise and late exercise are associated with a lower prevalence of non-calcified plaque compared to non-active people. Coronary CT angiography (CTCA) is a non-invasive method for assessing coronary artery disease and plays an important role in the identification and quantification of coronary atherosclerotic plaques. The primary endpoint was the prevalence of coronary plaque (including calcified, non-calcified plaque, and mixed plaque) on CTCA at baseline.
Study results
Participant baseline characteristics
The mean age of the participants (56.0±6.0) years, long-term exercisers and late-stage athletes mostly liked cycling, a few preferred triathlon, and non-athletes preferred running and other non-endurance sports. The cardiopulmonary function of long-term athletes and late-stage athletes was significantly higher than that of non-athletes (P<0.001), that is, the peak oxygen uptake (VO2peak, reflecting the level of cardiopulmonary function of the human body under extreme load) was 48 ml/min/kg, 46 ml/min/kg and 42 ml/min/kg, respectively.
Total burden of coronary atherosclerotic plaque
1) Number of plaques: The median number of plaques in long-term exercisers, late sportsmen and non-sports personnel was 2, 1 and 0, respectively, and the number of plaques was similar among the three.
2) Average coronary calcification score (CAC): The average scores of long-term exercisers, late sports personnel and non-sports personnel are 8.5 points, 1.3 points and 0 points, and the coronary artery calcium scores of the three are similar, but the percentile of long-term sports personnel is higher than that of non-sports personnel.
(Coronary artery calcification is a sign of coronary atherosclerotic lesions in patients, CAC can stratify the risk of cardiovascular disease, predict the occurrence of cardiovascular events, if CAC score = 0 points, indicating that the risk is very small, if the CAC score ≥ 1000 points, indicating a significantly increased risk of cardiovascular disease.) ）
▲The overall load of coronary atherosclerosis (Image source: Reference [1])
3) Involved segment stenosis score (SSS score) and involved segment number score (SIS) score: In terms of SSS and SSI, the SSS score and SIS score of long-term exercise personnel were higher than those of non-exercise personnel.
(SSS indicates the cumulative score of the number of segments in which coronary plaque is present and the corresponding degree of stenosis, and a score of 0 indicates a degree of stenosis of 0%, i.e., no stenosis; A score of 1 indicates a degree of stenosis < 50%, that is, mild stenosis; 2 points means that the degree of stenosis is 50%~70%, that is, moderate stenosis; A score of 3 indicates a degree of stenosis > 70%, that is, severe stenosis. SIS indicates the number of segments in the presence of coronary plaque, regardless of the degree of luminal stenosis, the range is 0~15 points. ）
4) Plaque properties: the nature distribution of plaques in long-term exercisers, late sports personnel and non-sports personnel was similar, and the proportion of calcified plaques was 62.3%, 68.4% and 67.0%, respectively; The proportion of non-calcified plaques was 11.8%, 9.8% and 13.7%, respectively. The proportion of mixed plaques was 25.9%, 21.8% and 19.3%, respectively.
(Plaque properties can be divided into calcified plaques, non-calcified plaques, and mixed plaques.) Calcified plaques are generally considered to be stable and non-calcified plaques are less stable. ）
5) Compared with non-exercisers, long-term athletes had higher risks, that is, lifelong endurance exercise was a risk factor for coronary plaque ≥1 (OR=1.86), proximal plaque ≥1 (OR=1.96), calcified plaque ≥1 (OR=1.58), proximal calcified plaque ≥1 (OR=2.07), non-calcified plaque ≥1 (OR=2.80), mixed plaque ≥1 (OR=1.96).
(Proximal plaque is a machine-recognized calcified plaque classified into specific coronary artery vascular branches, mainly segment 1 (right coronary artery), segment 5 (left main trunk), segment 6 (left anterior descending branch), and segment 11 (circumflex branch) to understand the specific situation of each branch coronary artery.) ）
Compared with late exercisers, long-term exercisers are more likely to have any coronary segmental stenosis ≥50% (OR=2.79) and proximal segmental stenosis ≥50% (OR=5.92).
▲Plaque type and coronary atherosclerotic load (Image source: Reference [1]) (A is ≥1 proximal calcified plaque, B is ≥1 proximal non-calcified plaque, C is ≥1 proximal mixed plaque, D is ≥50% narrow calcified plaque, E is ≥50% narrow non-calcified plaque, F is ≥50% stenosis mixed plaque)
Full text summary
The results of this study showed that long-term endurance exercise did not additionally avoid the risk of coronary atherosclerosis compared with an active and healthy lifestyle, on the contrary, long-term exercisers had a higher number of coronary plaques (including proximal unstable non-calcified plaques), that is, compared with non-exercisers, long-term endurance training people had a lower risk of cardiovascular events because of more stable plaques.
Based on the available results, the article suggests that the amount of exercise-risk between long-term endurance exercise and coronary atherosclerosis may be inverse J-type rather than descending logarithmic function, which needs to be supported by subsequent studies. A healthy lifestyle, above-average cardiopulmonary training and physical training can help prevent coronary atherosclerosis, resulting in more stable plaque and less unstable plaque, but the addition of endurance exercise training and enhanced physical fitness does not affect the distribution of plaque properties. In addition, long-term endurance athletes also have problems such as more coronary plaque and luminal stenosis.