I first link to and excerpt from 2020 ESC Guidelines on Sports Cardiology and Exercise for CVD Patients: Key Points [Full Text HTML]. Aug 31, 2020, Pelliccia A, Sharma S, Gati S, et al. from the American College of Cardiology.
Here are excerpts from Key Points above:
The following are key points to remember from the 2020 European Society of Cardiology (ESC) guidelines on sports cardiology and exercise in patients with cardiovascular disease (CVD):
- General: This is a comprehensive, well-organized document, covering a broad spectrum of cardiovascular (CV) conditions.
This document covers exercise recommendations in athletes with:
2. Cardiovascular Risk Factors: SCD is the leading cause of exercise-associated mortality in athletes; in athletes >35 years old, the majority of SCDs are attributed to coronary artery disease (CAD); preparticipation CV screening in recreational and competitive athletes is aimed at the detection of disorders associated with SCD; healthy adults of all ages and individuals with known CVD should exercise on most days for 150 minutes/week or more at a moderate-intensity level; establishing the maximal exercise capacity via a maximal exercise stress test (preferably cardiopulmonary exercise test [CPET]) facilitates exercise recommendations.
3. Chronic and Acute Coronary Syndrome: CV screening in adult athletes should include an assessment of CV risk factors and an exercise stress test; coronary artery calcium (CAC) scoring may be considered in asymptomatic athletes with a moderate atherosclerotic risk profile; individuals with low risk for exercise-induced adverse events are eligible for competitive or leisure sports activities, with few exceptions; competitive sports are not recommended in individuals with CAD at high risk of exercise-induced adverse events or those with residual ischemia; after an acute coronary syndrome event, cardiac rehabilitation and follow-up echocardiogram and exercise testing (CPET) are recommended; ischemia should be ruled out when evaluating an athlete with anomalous origin of the coronaries.
4. Chronic Heart Failure: Exercise programs improve exercise tolerance and quality of life but should be initiated only after medical therapy is optimized; a maximal exercise stress test (CPET) is important for baseline assessment of functional capacity, hemodynamic response, and arrhythmia inducibility with exercise; cardiac rehabilitation is a cornerstone of management of heart failure with preserved ejection fraction.
5. Aortopathy: Those with aortic root <40 mm are at lowest risk; risk stratification via exercise testing and imaging (computed tomography/cardiac magnetic resonance imaging) is recommended prior to exercise initiation; sports participation decreases the risk of CV events and mortality in athletes with aortopathies.
6. Cardiomyopathies, myocarditis, and pericarditis: In patients with hypertrophic cardiomyopathy, an individualized approach should be taken toward sports participation; individuals with acute myocarditis or pericarditis should avoid participation in sports while active inflammation is present; athletes with resolved myocarditis or pericarditis should undergo comprehensive CV evaluation, including an exercise test, to assess the risk of exercise-induced arrhythmias, usually 3-6 months after the diagnosis is made (sooner for pericarditis); a mildly reduced left ventricular ejection fraction (LVEF) with cavity enlargement could reflect physiologic adaptation or a dilated cardiomyopathy, necessitating assessment of LV function during exercise; high-intensity exercise has been shown to influence progression of arrhythmogenic cardiomyopathy and thus is not recommended.
8. Arrhythmias and channelopathies: Management is guided by three principles: (i) preventing life-threatening arrhythmias during exercise; (ii) symptom management; and (iii) preventing sports-induced progression of the arrhythmogenic condition; in athletes with supraventricular tachycardia (SVT), pre-excitation should be excluded, and curative treatment via catheter ablation should be considered; intermittent pre-excitation might be indicative of a low risk (i.e., for pre-excited atrial fibrillation (AF) accessory pathway, but adrenergic stimulation can enhance pre-excitation; if pre-excitation is manifest, ablation is recommended if SVT has been documented; in competitive, professional level athletes with asymptomatic pre-excitation, an electrophysiology study is recommended to rule out high-risk features; moderate-level exercise is recommended to prevent AF; for those with recurrent symptomatic AF, catheter ablation is recommended, especially in those not wanting to take or intolerant of medical therapy; atrial flutter ablation should be considered in those with documented flutter and could facilitate use of Class I antiarrhythmics for AF; athletes with premature ventricular contractions need to be evaluated for underlying structural or familial arrhythmogenic conditions; for athletes with inherited ion channelopathies, such as long QT syndrome and Brugada syndrome, shared decision making is indicated with cardiogeneticists and electrophysiologists as appropriate; patients with pacemakers should be encouraged to exercise but need to mindful of the underlying condition(s); exercise recommendations in the implantable cardioverter-defibrillator patient require shared decision making due to the potential for shocks during sports and potential consequences of syncope.
9. Congenital heart disease: Patients with congenital heart disease should be encouraged to exercise following physiological assessment of their condition; five baseline parameters to be evaluated are ventricular function, pulmonary artery pressure, aortic size, arrhythmia, and oxygen saturation; CPET is instrumental in the evaluation of this patient population.
In this post I link to the 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: The Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC) [PubMed Abstract] [Full Text HTML] [Full Text PDF].
The above article is incredibly complete. I have listed the direct links to the various sections of the article: