Running: The Risk of Coronary Events: Prevalence and Prognostic Relevance of Coronary Atherosclerosis in Marathon Runners

Stefan Möhlenkamp; Nils Lehmann; Frank Breuckmann; Martina Bröcker-Preuss; Kai Nassenstein; Martin Halle; Thomas Budde; Klaus Mann; Jörg Barkhausen; Gerd Heusch; Karl-Heinz Jöckel; Raimund Erbel


Eur Heart J. 2008;29(15):1903-1910. 

In This Article

Abstract and Introduction


Aims: To quantify the prevalence of coronary artery calcification (CAC) in relation to cardiovascular risk factors in marathon runners, and to study its role for myocardial damage and coronary events.
Methods and Results: In 108 apparently healthy male marathon runners aged ≥50 years, with ≥5 marathon competitions during the previous three years, the running history, Framingham risk score (FRS), CAC, and presence of myocardial late gadolinium enhancement (LGE) were measured. Control groups were matched by age (8:1) and FRS (2:1) from the Heinz Nixdorf Recall Study. The FRS in marathon runners was lower than in age-matched controls (7 vs. 11%, P < 0.0001). However, the CAC distribution was similar in marathon runners and age-matched controls (median CAC: 36 vs. 38, P = 0.36) and higher in marathon runners than in FRS-matched controls (median CAC: 36 vs. 12, P = 0.02). CAC percentile values and number of marathons independently predicted the presence of LGE (prevalence = 12%) (P = 0.02 for both). During follow-up after 21.3 ± 2.8 months, four runners with CAC ≥ 100 experienced coronary events. Event-free survival was inversely related to CAC burden (P = 0.018).
Conclusion: Conventional cardiovascular risk stratification underestimates the CAC burden in presumably healthy marathon runners. As CAC burden and frequent marathon running seem to correlate with subclinical myocardial damage, an increased awareness of a potentially higher than anticipated coronary risk is warranted.


Regular physical exercise improves the cardiovascular risk profile and reduces cardiovascular disease (CVD) morbidity and mortality.[1,2] Vigorous exercise, on the other hand, increases the short-term risk of coronary events.[3] Coronary atherosclerosis is the main underlying cause of exercise-related coronary events not only among elderly persons unaccustomed to exercise,[4] but also in adult athletes including marathon runners.[5,6]

Over the past decades, the number of recreational marathon runners, including those at older age, is constantly rising. This trend may have implications for pre-participation cardiovascular risk stratification. Identification of marathon runners at risk is difficult and the need for cardiovascular medical examinations remains controversial.[7,8] The risk of sudden cardiac death associated with marathon running has been suggested to be too low to recommend routine screening for coronary artery disease (CAD).[9] In master athletes, pre-participation medical evaluations are nonetheless advised as a prudent measure before entering master sports training programmes.[8,10] Standard clinical exercise tests can, however, be normal, even in the presence of rupture-prone coronary plaques.[5,11,12]

Based on prospective studies in various cohorts,[13] it is speculated that advanced coronary artery calcification (CAC) in endurance athletes may be associated with an increased risk of cardiac events.[5] Yet, the role of subclinical coronary atherosclerosis in cardiovascular risk assessment has not been studied in marathon runners. In patients with CAD, the presence of cardiac magnetic resonance imaging (cMRI)-based myocardial late gadolinium enhancement (LGE) may reflect prior myocardial damage and is associated with an impaired prognosis,[14] but its association with subclinical CAC burden in healthy marathon runners is unknown.

This study was designed to quantify the prevalence of CAC in relation to cardiovascular risk factors in marathon runners, and to study its role for myocardial damage and coronary events.


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