Atherosclerosis is a progressive inflammatory disease with a characteristic feature of the accumulation of lipid-laden plaques within arterial walls.1 It is a leading cause of cardiovascular disease and mortality worldwide.2,3 While traditionally associated with older populations and individuals with metabolic risk factors, its prevalence in the younger generation is also on the increase.4, 5, 6 Sudden cardiac death (SCD) is an unexpected, natural death caused by an abrupt loss of heart function in a person with or without known pre-existing heart disease.7 SCD occurs within one hour of symptom onset and is usually due to electrical disturbances that disrupt the heart’s ability to pump blood effectively.8 SCD is the leading cause of sudden death in athletes.9 The leading underlying cause of SCD is Atherosclerotic Vascular Disease (ASVD), principally atherosclerotic CAD is the most common cause of SCD in athletes.10 The intense hemodynamic stress induced by high-performance training may exacerbate plaque instability, predisposing athletes to acute coronary syndromes or fatal arrhythmias.11

Interestingly, while regular exercise is well known to reduce cardiovascular risk by improving lipid metabolism, vascular function, and overall cardiac health, excessive or extreme endurance training may induce adverse vascular remodeling, increased oxidative stress, and chronic inflammation thus potentially accelerating atherosclerotic progression.12,13 This review, therefore, explores the relationship between atherosclerosis and SCD in athletes, examining pathophysiological mechanisms, risk factors, and the impact of exercise intensity. Additionally, it discusses current screening strategies and preventive measures to reduce cardiovascular risks while preserving the benefits of athletic training. Understanding these dynamics is key in the development of tailored approaches to athlete screening and cardiovascular health management, ultimately reducing the incidence of SCD in this unique population.