If you’re a masters endurance athlete, coronary artery disease (CAD) is something you need to understand, whether you feel healthy or not.
Research continues to show that highly trained, fit athletes are not immune to CAD. In many cases, the disease develops silently. Standard screening often fails to detect it, and symptoms may not appear until a catastrophic event occurs.
CAD and Masters Athletes: The Reality
Coronary artery disease is the leading cause of sudden cardiac death in male athletes over the age of 35. Many athletes diagnosed with CAD report no warning signs at all, and their fitness levels often mask underlying risk.
Being active is protective in many ways, but fitness alone does not guarantee protection from heart disease.
When Fitness Isn’t Enough
Moderate exercise is well established as heart-protective. However, emerging research suggests that long-term, high-volume, high-intensity endurance training may increase the likelihood of developing coronary plaque in some athletes.
This does not mean endurance sports are dangerous. It does mean the risk profile of athletes can differ from that of the general population.
The Most Dangerous Plaques Often Go Undetected
One of the most concerning findings in athlete research is that the most dangerous plaques are often non-obstructive. These plaques do not significantly block blood flow, which means:
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They often do not cause symptoms
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They frequently do not appear on standard stress tests
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They can still rupture suddenly, triggering a heart attack
This is why athletes with excellent performance and normal test results can still experience serious cardiac events.
Why Conventional Screening Can Miss CAD
Many athletes are reassured by routine screening, but conventional tools often fall short in this population.
Resting ECGs, exercise stress tests, cholesterol levels, and physical exams can all appear normal even when significant coronary artery disease is present. In fact, up to one-third of people with confirmed CAD have a normal ECG.
For athletes, this can create a false sense of security.
Advanced Imaging Is Changing Detection
Newer imaging tools are improving how CAD is identified in athletic populations.
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Coronary Calcium Scoring (CS) can detect early atherosclerosis and improve risk assessment
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Coronary CT Angiography (CCTA) allows clinicians to see plaque type, burden, and location, even when arteries are not blocked
These tools are increasingly recommended for masters athletes, particularly those with high training volumes or long competitive histories.
Hidden Disease Is More Common Than Many Think
Multiple studies have found that a significant number of asymptomatic, low-risk male athletes show evidence of occult CAD on CCTA, in some cases approaching 20 percent.
Research also consistently shows that high-mileage and high-intensity athletes tend to have higher coronary calcium scores than their lower-volume peers.
Most Athletes Diagnosed With CAD Feel Fine
In screening studies, approximately 90 percent of athletes diagnosed with CAD reported no symptoms at all. Fatigue is often normalized. Performance dips are attributed to age or training load. Warning signs are dismissed or pushed through.
High fitness does not erase risk. It can sometimes hide it.
Why Athlete-Specific Screening Matters
Traditional cardiovascular risk calculators were designed for the general population and do not perform well in endurance athletes. There is growing support for developing athlete-specific screening protocols, including the thoughtful use of advanced imaging when appropriate.
The goal is not fear. The goal is informed decision-making.
The Bottom Line
Endurance athletes are disciplined, resilient, and deeply in tune with their bodies. That same mindset can lead to overlooked symptoms and misplaced reassurance.
Being fit does not mean being immune.
Understanding CAD, asking better questions, and advocating for appropriate screening can be life-saving.
To support informed conversations with health care providers, we've created a downloadable resource that brings together the research referenced in this article.