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....................................................................................... individual risk factors such as very high total cholesterol and lowdensity lipoprotein (LDL), diabetes mellitus, or a strong family history of CVD.6 Based on this assessment the individual CV risk can be categorized from low to very high risk (Table 5).

Preliminary evaluation should consist of a self-assessment relating to symptoms and calculation of SCORE. Individuals who are habitually active and at low or moderate risk should not have any restrictions for exercise including competitive sports. Sedentary individuals and individuals at high or very high risk may engage in low-intensity exercise without further evaluation. Sedentary individuals and/or those at high or very high risk planning to undertake high-intensity exercise as well as selected individuals planning to undertake moderate-intensity exercise should undergo a physical examination, 12-lead ECG, and exercise stress test. The aim of the exercise test is to identify prognostically important CAD and to assess the presence of exercise-induced arrhythmias. Individuals with symptoms, abnormal findings on physical examination, abnormal ECG, or abnormal exercise test should be investigated further according to current ESC Guidelines for chronic coronary syndromes.110 Following normal investigations, there should be no restrictions to sports participation. All individuals should, however, be thoroughly informed that development of symptoms during exercise should prompt reassessment.

While a normal exercise test and a high exercise capacity is associated with a good prognosis, the test has limited sensitivity in diagnosing mild to moderate obstructive CAD.111,112 Currently there is no evidence for incorporating routine cardiac imaging in preparticipation screening among asymptomatic individuals aged >35 years old with a normal exercise stress test. However, in asymptomatic adults considered to be at high risk or very high risk (diabetes, strong family history of CAD, previous risk assessment suggesting high risk for CAD) a functional imaging test or coronary computed tomography angiography (CCTA) should be considered in the risk assessment (Figure 4).110 Identification of atherosclerotic CAD should prompt aggressive management of risk factors and preventive medical treatment. Among individuals with proven obstructive CAD, further assessment and treatment is indicated.

Table 5 Cardiovascular risk categories

©ESC 2020 General recommendations for exercise and sports in healthy individuals

Recommendations Classa Levelb

At least 150 min/week of moderate-intensity, or 75 min/week of vigorous-intensity aerobic exercise, or an equivalent combination thereof is recommended in all healthy adults.113118 I A A gradual increase in aerobic exercise to 300 min/week of moderate-intensity, or 150 min/ week of vigorous-intensity aerobic exercise, or an equivalent combination is recommended for additional benefits in healthy adults.114,116 I A Regular assessment and counselling to promote adherence and, if necessary, to support an increase in exercise volume over time are recommended.119 I B Multiple sessions of exercise spread throughout the week, i.e. on 45 days a week and preferably every day of the week, are recommended.113,114 I B

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