Intense exercise encourages coronary artery calcification

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Exercise and physical activity reduce the risk of cardiovascular disease (CVD). It has been observed that an active individual is at a 30% to 40% lower risk of CVD. However, previous cross-sectional studies have failed to determine whether exercise has a significant impact on expediting coronary atherosclerosis and plaque morphology. A recent Circulation journal paper has focused on investigating the relationship between exercise volume and intensity and the progression of coronary atherosclerosis in middle-aged and older male athletes.

Study: Exercise Volume Versus Intensity and the Progression of Coronary Atherosclerosis in Middle-Aged and Older Athletes: Findings From the MARC-2 Study. Image Credit: sciencepics / ShutterstockStudy: Exercise Volume Versus Intensity and the Progression of Coronary Atherosclerosis in Middle-Aged and Older Athletes: Findings From the MARC-2 Study. Image Credit: sciencepics / Shutterstock


Coronary artery calcification (CAC) is a biomarker for coronary atherosclerotic plaque burden and future risk of CVD events. This biomarker can be measured using the computed tomography (CT) imaging. In addition, a more detailed study of coronary plaque morphology can be carried out using Coronary CT angiography (CCTA).

Typically, athletes have CAC scores ≥100 Agatston units, linked to lifelong exercise volume and intensity of exercise training. In active athletes, atherosclerotic plaque morphology has been found to be more calcified or partially calcified. In addition, recent studies have indicated that amateur athletes have higher coronary atherosclerosis compared to less active healthy controls.

About the Study

The current study used CAC scoring and CCTA to evaluate the relationship between exercise training characteristics and coronary atherosclerosis in middle-aged and older male athletes. This study hypothesized that greater volume and exercise intensity are associated with a higher incidence of coronary atherosclerosis.

The present study is known as the MARC-2 (Measuring Athletes' Risk of Cardiovascular Events 2), a follow-up of the MARC-1 (Measuring Athletes' Risk of Cardiovascular Events 1) study.

The MARC-2 study recruited asymptomatic middle-aged and older men above 45 years of age and did not show any abnormalities in their sport's medical evaluation between May 2019 and February 2020. Individuals who underwent a percutaneous coronary intervention during follow-up were excluded.

Relevant information about the exercise characteristics of the participants was obtained via a validated questionnaire. This questionnaire focussed on collecting information about the type of sport, frequency, duration for each sport (in years), duration of an exercise session, and level of performance, i.e., recreational vs. competitive, of the study cohort.

A metabolic equivalent of task (MET) for all reported sports was assigned based on the Compendium of Physical Activities. The current study used exercise volume, expressed in MET hours/week, during the study period.

Study Findings

The current study included a total of 291 men. Based on the eligibility criteria, 287 men were finally included in the MARC-2 CAC analyses and 284 in the plaque analyses. It was observed that the average follow-up between CT scans was 6.3 years. Additionally, blood pressure levels and the use of antihypertensives and statins had substantially increased in the follow-up period. However, the cholesterol level of the participants remained the same throughout the follow-up period. Six participants had also quit smoking.

Exercise intensity, but not volume, was correlated with the progression of coronary atherosclerosis. The impact of vigorous exercise was found to be less effective in CAC progression; however, very vigorous exercise was associated with a more significant progression of CAC and plaque (calcified). This finding is in line with cross-sectional MARC-1 observation that revealed specific exercise intensities rapidly enhance the development of calcified plaque.

Exercise with a very high level of intensity has been associated with the formation of calcified plaque, which suggests that certain mechanisms may be involved in facilitating coronary atherosclerosis in athletes. For instance, higher-intensity exercise produces higher catecholamine levels, which can increase an individual's heart rate and blood pressure. According to previous studies, increased heart rate expedites atherosclerosis, possibly due to the increased frequency of turbulent blood flow.

No correlation was found between exercise volume and the progression of coronary atherosclerosis during the follow-up. The finding of this study is in line with previous research, which revealed that 74% of recreational athletes had no significant difference in exercise volume between individuals with or without progression of CAC after 4.1 years of follow-up. It is possible that exercise volume is associated with coronary atherosclerosis initiation but not with its progression. More research is required to determine the differences in atherosclerosis based on exercise intensity, i.e., within the separate groups (running and cycling).


Over the 6-year follow-up period, exercise intensity was associated with the progression of coronary atherosclerosis, but not exercise volume. It is noteworthy that very vigorous intensity exercise was associated with significantly higher CAC and calcified plaque progression, whereas vigorous intensity exercise was associated with less CAC progression.

Journal reference:
Dr. Priyom Bose

Written by

Dr. Priyom Bose

Priyom holds a Ph.D. in Plant Biology and Biotechnology from the University of Madras, India. She is an active researcher and an experienced science writer. Priyom has also co-authored several original research articles that have been published in reputed peer-reviewed journals. She is also an avid reader and an amateur photographer.


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  1. Paul Dodd Paul Dodd Switzerland says:

    These sentences seem incompatible;

    It is possible that exercise volume is associated with coronary atherosclerosis initiation but not with its progression.

    Atherosclerosis prevalence and severity were found to increase with lifelong exercise volume in athletes.

  2. Michael Watts Michael Watts United States says:

    Its not so much the higher intensity of exercise contributing to higher levels of CAC its how individuals eat on a day to day that will predicate what there CAC levels will be. Again these studies dont factor in other major variables. Flawed science

    • Sushi Kitty Sushi Kitty United States says:

      The researchers did not make the participants eat a certain diet because in the general population we all have different diets. Therefore, you have to accept what everyone eats to get a general consensus. If participants were only eating a particular type of food group considered "healthy", (which nobody can really agree on what that is today), then the results would be skewed and biased.

  3. My Self My Self United States says:

    it is likely that a significant number of individuals in the data sample who consistently engage in high intensity and high volume workouts likely have a higher rate of caffeine and stimulant consumption than the average non-athletic or less active individuals in a population. long-term consumption of higher levels of caffeine may likely be a significant contributing factor in the CAC, and was not a stated data point in the participant questionnaire.  curious...  i would like to see the overlapping data on caffeine intake and CAC in the same group.

    • Sushi Kitty Sushi Kitty United States says:

      While Caffeine is indeed a stimulant, and it has its pros and cons when considering health, I have not seen any studies that show it causes or increases calcification. Caffeine does indeed constrict blood vessels, which you can assume would not be a good thing if they are calcified. But as far as generating or increasing calcification I haven't seen any studies that state this about caffeine. If you have please post links. Thank you.

  4. Sridhar Narayanan Sridhar Narayanan U.A.E. says:

    In a nutshell moderation the key to healthy  living

  5. Vern McMillan Vern McMillan United States says:

    Be interesting to establish whether the high intensity group also had a higher percentage intake of protein in their diets, especially animal protein.

    • Sushi Kitty Sushi Kitty United States says:

      Great point! Especially when you consider in many ethnic groups the consumption of milk and dairy is not a daily event. Calcium in plants is absorbed very slowly, whereas through dairy products it is intense. May that cause or contribute to calcification? Just as they now are recommending to no longer take calcium carbonate as a supplement due to calcification issues proven in studies.

  6. Tom Spradley Tom Spradley Mexico says:

    So is it good or bad, protective or dangerous -- in non medical non statistical language?

  7. Al Leon Al Leon United States says:

    What county were the participants from?
    What diet were they on? A few questions about a study that goes against conventional wisdom. By the way, I don't believe the results.

    • Sushi Kitty Sushi Kitty United States says:

      Remember my friend: Just because you don't like the results doesn't mean the study is flawed. It just means you don't like the results. But I think it is safe to assume that the participants were on a Western diet, as usually in studies that are not done with Western participants it is stated what country they are from. Researchers have nothing to gain from a study like this, so there is no reason to distrust it, unless you have proof otherwise.

  8. RJ Reynaud RJ Reynaud United States says:

    It's a balance not to over the key is a balanced exercise routine with mobility, strength, and cardiovascular training as to be intermediate between the two.

  9. Carl Krekorian Carl Krekorian United States says:

    I'm an avid cyclist and ride 6days a week 365day and average around 10k miles, so needless to say I'm very interested in this study as I've been recently determined to have CAC.What was the definition of vigorous and very vigorous in terms of maximum heart rate? Using the standard 220 minus your age would that be considered vigorous or very vigorous.

  10. Mark Songi Mark Songi United Kingdom says:

    I wonder what the outcomes where for these patients?

    Another study I believe found similar higher CAC scores in high exercisers but lower cardiac disease.

    DeFina, L. F., et al. (2019), Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification, JAMA Cardiology 4:174–81.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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