Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

On the paradox of exercise: coronary atherosclerosis in an apparently healthy marathon runner


Background An asymptomatic and apparently healthy 64-year-old marathon runner underwent comprehensive cardiovascular risk assessment as part of a prospective study on calcified coronary plaque burden in master marathon runners. His profile suggested a low 10-year cardiovascular risk.

Investigations Conventional risk-factor assessment, coronary artery calcium quantification, bicycle stress test, echocardiography, coronary angiography, intravascular ultrasonography, including virtual histology, and intracoronary Doppler ultrasonography.

Diagnosis Severe coronary atherosclerosis of the left anterior descending, mid left circumflex, and left main arteries.

Management Stenting of the left anterior descending artery, CABG surgery, and intensive risk-factor modification. The patient was also advised against participating in future marathon competitions.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Get just this article for as long as you need it


Prices may be subject to local taxes which are calculated during checkout

Figure 1: Coronary angiogram demonstrating marked lumen reduction in the mid LAD and mid LCX (arrows)
Figure 2: Intracoronary Doppler ultrasound scans demonstrating blood flow in the stenosed LAD and the non-stenosed RCA
Figure 3: Intravascular ultrasound virtual histology image of a single plaque in the left anterior descending artery, demonstrating a relatively high amount of necrotic core plaque component (14%), as marked in red
Figure 4: Intracoronary Doppler ultrasound scan of the distal LAD after stent deployment


  1. Möhlenkamp S et al. (2006) Coronary atherosclerosis and cardiovascular risk in master male marathon runners: rationale and design of the 'Marathon Study'. Herz 31: 575–585

    Article  Google Scholar 

  2. National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) (2002) Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III) final report. Circulation 106: 3143–3421

  3. Schmermund A et al. (2006) Population-based assessment of subclinical coronary atherosclerosis using electron-beam computed tomography. Atherosclerosis 185: 177–182

    Article  CAS  Google Scholar 

  4. Wieneke H et al. (2000) Corrected coronary flow velocity reserve: a new concept for assessing coronary perfusion. J Am Coll Cardiol 35: 1713–1720

    Article  CAS  Google Scholar 

  5. Rodriguez-Granillo GA et al. (2005) In vivo intravascular ultrasound-derived thin-cap fibroatheroma detection using ultrasound radiofrequency data analysis. J Am Coll Cardiol 46: 2038–2042

    Article  Google Scholar 

  6. Mittleman MA et al. (1993) Triggering of acute myocardial infarction by heavy physical exertion; protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med 329: 1677–1683

    Article  CAS  Google Scholar 

  7. Maron BJ (2000) The paradox of exercise. N Engl J Med 343: 1409–1411

    Article  CAS  Google Scholar 

  8. Noakes TD et al. (1979) Autopsy-proved coronary atherosclerosis in marathon runners. N Engl J Med 301: 86–89

    Article  CAS  Google Scholar 

  9. Maron BJ et al. (2001) Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: an advisory for healthcare professionals from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 103: 327–334

    Article  CAS  Google Scholar 

  10. Roberts WO and Maron BJ (2005) Evidence for decreasing occurrence of sudden cardiac death associated with the marathon. J Am Coll Cardiol 46: 1373–1374

    Article  Google Scholar 

  11. Greenland P et al. (2007) ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 49: 378–402

    Article  Google Scholar 

  12. Thompson PD et al. (2005) Task force 6: coronary artery disease. J Am Coll Cardiol 45: 1348–1353

    Article  Google Scholar 

  13. Rodriguez-Granillo GA et al. (2006) Coronary plaque composition of nonculprit lesions, assessed by in vivo intracoronary ultrasound radio frequency data analysis, is related to clinical presentation. Am Heart J 151: 1020–1024

    Article  Google Scholar 

  14. Fassa AA et al. (2005) Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a long-term follow-up study. J Am Coll Cardiol 45: 204–211

    Article  Google Scholar 

  15. Rauramaa R et al. (2004) Effects of aerobic physical exercise on inflammation and atherosclerosis in men: the DNASCO study—a six-year randomized, controlled trial. Ann Intern Med 140: 1007–1014

    Article  Google Scholar 

  16. Desai MY et al. (2004) Relation of degree of physical activity to coronary artery calcium score in asymptomatic individuals with multiple metabolic risk factors. Am J Cardiol 94: 729–732

    Article  CAS  Google Scholar 

  17. Kojda G and Hambrecht R (2005) Molecular mechanisms of vascular adaptations to exercise: physical activity as an effective antioxidant therapy? Cardiovasc Res 67: 187–197

    Article  CAS  Google Scholar 

  18. Suzuki K et al. (2003) Impact of a competitive marathon race on systemic cytokine and neutrophil responses. Med Sci Sports Exerc 35: 348–355

    Article  CAS  Google Scholar 

  19. Siegel AJ et al. (2001) Effect of marathon running on inflammatory and hemostatic markers. Am J Cardiol 88: 918–920

    Article  CAS  Google Scholar 

  20. Neilan TG et al. (2006) Myocardial injury and ventricular dysfunction related to training levels among nonelite participants in the Boston marathon. Circulation 114: 2325–2333

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Stefan Möhlenkamp.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Related links

Related links

Web links

Does preparticipation cardiovascular screening of athletes save lives?

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Möhlenkamp, S., Böse, D., Mahabadi, A. et al. On the paradox of exercise: coronary atherosclerosis in an apparently healthy marathon runner. Nat Rev Cardiol 4, 396–401 (2007).

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI:

This article is cited by


Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing