A joint clinical consensus statement from the European Society of Cardiology and the American College of Cardiology says Masters athletes — adults aged 35 years or older who regularly compete and whose exercise habits exceed standard physical activity recommendations — may have a higher prevalence of some cardiovascular abnormalities, including atrial arrhythmias, coronary atherosclerosis, aortic dilatation, and myocardial fibrosis.
The document provides an expert consensus-based update on the diagnostic assessment, management, and prognosis of atrial fibrillation, bradyarrhythmias, ventricular arrhythmias, coronary atherosclerosis, aortic dilatation, myocardial fibrosis, and exercise-induced arrhythmogenic cardiomyopathy in this population. The researchers noted that current management strategies are largely based on data from sedentary patients and may not fully apply to highly trained athletes.
Atrial Fibrillation Risk Appears Higher With Endurance Exercise
The statement says Masters athletes have a lower prevalence of traditional risk factors for atrial fibrillation, such as hypertension, obesity, and diabetes, but a higher prevalence and incidence of atrial fibrillation. Among Masters athlete Nordic skiers, atrial fibrillation prevalence was about twice that seen in comparable members of the general population, and adjusted estimates in Masters athletes ranged from 2.5 to 4. Greater exercise duration and intensity were associated with greater risk.
Proposed mechanisms include atrial enlargement related to pressure and volume overload, autonomic changes, electrical remodeling, and atrial fibrosis. For symptomatic Masters athletes, rhythm control is generally preferred over rate control because beta-blockers, calcium antagonists, and digoxin may be poorly tolerated during exercise. The statement says pulmonary vein isolation is a reasonable early treatment option in selected athletes, although shared decision-making remains important because complications can affect sports performance.
Coronary Calcification May Be More Common in Male Masters Athletes
The consensus statement says regular exercise improves many atherosclerotic risk factors, but coronary calcification and atherosclerosis appear to be more common in male, though not female, Masters endurance athletes compared with less active peers. It also describes a non-linear association between lifelong exercise volume and the prevalence of coronary artery calcium scores above 100 Agatston units.
Earlier studies suggested plaques in athletes were predominantly calcified, raising the possibility that exercise may promote plaque stabilization, although the statement notes that findings have not been fully consistent across studies.
The document also cites data from the Cooper Center Longitudinal Study showing that men with coronary artery calcium scores below 100 who reported high exercise volumes had lower all-cause mortality than less active peers with similarly low scores. By contrast, among men with scores of 100 or greater, event rates did not differ meaningfully by exercise volume. The statement concludes that higher fitness may lessen overall risk but does not eliminate the risk associated with higher coronary calcium scores. Figure 4 on page 10 summarizes that pattern.
For management, the researchers say Masters athletes with cardiovascular risk factors should receive lifestyle counseling and guideline-based pharmacologic treatment as recommended for the general population. For asymptomatic athletes at low cardiovascular risk, routine screening with coronary artery calcium scoring is not recommended.
Aortic Dilatation Findings Vary by Sport History
The statement says data on aortic dilatation in older athletic populations remain limited and variable. Mild aortic dilatation of 40 to 45 mm was reported in about 20% of Masters runners and rowers, while prevalences as high as 41% were reported in former elite strength athletes, including American football and rugby players. Figure 5 on page 12 displays those percentages.
The researchers say sport-specific long-term training, possibly combined with traditional cardiovascular risk factors, idiopathic aortic disease, and prohibited substance use, may contribute to larger aortic dimensions in some athletes. However, they also emphasize that the contribution of sport type to aortic dilatation and aortic events in Masters athletes remains unclear.
Management should focus on comprehensive evaluation, blood pressure control, and surveillance imaging. The statement says Masters athletes with aortic dilatation of 40 to 44 mm and no heritable cause are generally considered at low risk and may reasonably continue competitive sports with appropriate follow-up. Athletes with aortic dimensions of 45 to 50 mm require individualized evaluation, and those meeting established surgical thresholds of 50 mm or greater should be counseled to avoid competitive sports and high-intensity exercise training.
Myocardial Fibrosis Remains Difficult to Interpret
The reported prevalence of myocardial fibrosis, assessed by late gadolinium enhancement on cardiac magnetic resonance imaging, ranged from 3% to 50% across studies included in the statement. Table 6 on page 15 shows that wide variation and highlights major differences in study design and athlete populations.
The statement says this variability likely reflects differences in age, sex, sport type, and training history, along with small sample sizes, selection bias, limited controls, and incomplete information on confounders such as performance-enhancing drug use. The researchers say the finding can create a diagnostic challenge because it may represent either benign adaptation or early cardiomyopathy, depending on clinical context and the pattern and extent of fibrosis.
The document also notes that myocardial fibrosis may serve as a substrate for ventricular arrhythmias. Still, it distinguishes between isolated late gadolinium enhancement at right ventricular insertion points, which is not associated with adverse outcomes and does not require further evaluation in asymptomatic athletes, and more extensive patterns that warrant additional risk stratification.
Shared Decision-Making Is Central
The statement says the clinical assessment of Masters athletes generally follows routine cardiovascular practice but includes several population-specific challenges. These include reduced exercise capacity as a presenting complaint, reluctance to start pharmacologic therapy because of performance concerns, increasing availability of wearable health data, and limited athlete-specific evidence to guide treatment.
The researchers repeatedly emphasize shared decision-making, incorporating symptoms, prognosis, available evidence, athletic goals, and the potential benefits and harms of treatment and exercise modification.
Important Evidence Gaps Remain
The statement emphasizes that important uncertainties remain across all of these conditions. It says best practices still rely heavily on expert consensus and extrapolation from the general population because no clinical trials or randomized controlled trials have focused exclusively on athletes, including Masters athletes.
Key unanswered questions include the clinical significance of coronary plaque patterns, the mechanisms underlying atrial fibrillation, aortic dilatation, and myocardial fibrosis in Masters athletes, and the causes and prognosis of exercise-induced arrhythmogenic cardiomyopathy.
“Cardiac care for Masters athletes should include comprehensive traditional CV risk factor assessment, lifestyle counselling, and medical therapy when appropriate,” wrote lead researcher Thijs M.H. Eijsvogels of Radboud University Medical Center in the Netherlands, and colleagues.
The statement reported nothing to declare. T.M.H.E. reported support from the Dutch Heart Foundation.
Source: JACC
