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.............................................................................................................................................................. reduction in body weight is achieved. Moreover, if high-volume exercise (>2 h/day) is desired, a sufficient recovery time should be allowed for between periods of exercise (optimally 48 h). It is important to emphasize that good physical and muscular fitness and neuromuscular coordination may protect obese individuals from musculoskeletal injuries, hence non-weight-bearing exercises such as cycling or swimming128 may be beneficial. Finally, there is no compelling evidence that resistance training, when executed properly, will increase the risk for musculoskeletal injuries or provoke musculoskeletal symptoms in obese individuals.129

4.2.3 Hypertension A person with a persistent systolic BP (SBP) >_140 mmHg and/or diastolic BP (DBP) >_90 mmHg is considered hypertensive.130,131 Hypertensive individuals should participate in at least 30 min of moderate-intense dynamic aerobic exercise (walking, jogging, cycling, or swimming) for 57 days per week.132 Such exercise intervention is associated with a mean reduction in SBP of 7 mmHg and DBP of 5 mmHg.133 Additional resistance training is highly effective in reducing BP further and resistance training 23 days per week is also advised.132 Indeed, the BP-lowering effect of resistance and isometric exercise may be comparable to, or even greater than, that of aerobic exercise.134 If high-intensity sports participation is desired, a pre-participation CV assessment is warranted to identify athletes with exerciseinduced symptoms, excessive BP response to exercise130, and the presence of end organ damage. Individuals with symptoms suggestive of CAD require further assessment and optimization of medical therapy before participation in sports. If arterial hypertension is poorly controlled (resting SBP > 160 mmHg), a maximal exercise test should be postponed until the BP is controlled. Non-pharmacological measures should be considered as the first step in the management of hypertension in athletes, including: restriction of salt intake and alcohol consumption, weight reduction if applicable, balanced diet (e.g. Mediterranean diet), and cessation of smoking. Aerobic exercise programmes should herein complement the individual’s training schedule.131 If such lifestyle changes do not lower BP after 3 months, antihypertensive drugs should be commenced if SBP remains >140 mmHg. Antihypertensive therapy alongside lifestyle intervention should be considered in all individuals aged >65 years but <80 years, provided it is well tolerated.131,132 It is important to consider that beta-blockers are prohibited in certain competitive skill sports such as shooting [see World Anti-Doping Association (WADA) for complete list135], and can induce bradycardia and/ or lower aerobic exercise capacity.131 Diuretics are prohibited in all competitive sports.135Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and calcium antagonists are the preferred drugs of choice in exercising individuals. It is noteworthy that the use of non-selective non-steroidal inflammatory drugs for musculoskeletal pain may contribute to raised BP.136

When BP is uncontrolled, temporary restriction from competitive sports is recommended, with the possible exception of skill sports.131 In individuals with a high-risk profile, including those with end organ damage [left ventricular (LV) hypertrophy, diastolic dysfunction, ultrasound evidence of arterial wall thickening or atherosclerotic plaque, hypertensive retinopathy, increased serum creatinine (men 1.31.5 mg/dL, women 1.21.4 mg/dL), and/or microalbuminuria] in whom BP is controlled, participation in all competitive sports is possible, with the exception of the most intensive power disciplines such as discus/javelin throwing, shot-putting, and weightlifting (see section 4.1).131 During sports participation, regular follow-up is recommended depending on the severity of hypertension and the category of risk. In individuals with borderline BP readings, regular ambulatory assessment of BP should be considered. In individuals with low or moderate CV risk and well-controlled BP, there should be no restrictions to sports participation, however, intensive heavy weightlifting, especially when this includes substantial isometric (static) muscle work, can have a marked pressor effect and should be avoided. In this context, avoiding the Valsalva manoeuvre in particular is warranted because breath holding during muscular contraction is associated with a greater elevation in SBP and DBP.135 When executed correctly, high-intense dynamic resistance training (up to 80% of 1 RM), with a low number of repetitions (n < 10) does not induce greater increments in BP compared with low-intense dynamic resistance training (<50% of 1 RM) with a high number of repetitions (n >_ 20).137142 Some individuals who are normotensive at rest will have an exaggerated BP response to exercise. An exaggerated BP response to exercise increases the risk for incident hypertension in highly trained and normotensive athletes over a middle-term period.143 If SBP rises to >200 mmHg at a workload of 100 W during exercise testing,144 antihypertensive medical therapy should be optimized and clinical evaluation, including ECG and echocardiography, should be considered, even if the athlete is normotensive at rest.131 Moreover, in young Olympic athletes a peak SBP of >220 mmHg in males and >200 mmHg in females measured during cycle ergometry are beyond the 95th percentile.131

4.2.4 Dyslipidaemia Physical activity has favourable effects on lipid metabolism by reducing serum triglycerides by up to 50% and increasing high-density lipoprotein (HDL) cholesterol by 510%.85,145 Exercise may also reduce LDL cholesterol by up to 5% and shift the more atherogenic small, dense LDL fraction towards larger LDL particles in a dosedependent fashion.146 These metabolic improvements can be achieved through 3.5 - 7 h of moderately vigorous PA per week or 30 - 60 min of exercise on most days. In individuals with hypertriglyceridaemia or hypercholesterolaemia, a higher intensity of exercise is recommended, as this may Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026