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Basil S. Lewis (Israel), Lluis Mont (Spain), Christian Mueller (Switzerland), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Marco Roffi(Switzerland), Kai Savonen (Finland), Luis Serratosa (Spain), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Marta Sitges (Spain), Erik Ekker Solberg (Norway), Miguel Sousa-Uva (Portugal), Emeline Van Craenenbroeck (Belgium), Caroline Van De Heyning (Belgium), William Wijns (Ireland) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online.

Click here to access the corresponding chapter in ESC CardioMed - section 55 - Sports and heart disease

................................................................................................................................................................................................... Keywords Guidelines • adult congenital heart disease • aortopathies • arrhythmias • cancer • cardiomyopathy • cardiovascular risk factors • chronic coronary syndromes • exercise • heart failure • pregnancy • peripheral vascular disease • recommendations • risk stratification • sport  special environments • valvular heart disease

Table of Contents

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3 Identification of cardiovascular disease and risk stratification in individuals participating in recreational and competitive sports . . . . . . . 25 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 3.2 Definitions of recreational and competitive athletes . . . . . . . . . . . 25 3.3 Exercise-related major adverse cardiovascular events . . . . . . . . . 25 3.4 Incidence of sudden cardiac death in athletes . . . . . . . . . . . . . . . . . 26 3.5 Aetiology of sudden cardiac death during exercise . . . . . . . . . . . . 26 3.6 Screening modalities for cardiovascular disease in young athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 3.7 Screening for cardiovascular disease in older athletes . . . . . . . . . . 26 4 Physical activity, leisure exercise, and competitive sports participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

4.1 General introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.1.1 Definition and characteristics of exercise interventions . . . . 27 4.1.1.1 Type of exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.1.1.2 Exercise frequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.1.1.3 Exercise intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.1.1.4 Training volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.1.1.5 Type of training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.1.2 Classification of exercise and sports . . . . . . . . . . . . . . . . . . . . . . 29 4.2 Exercise recommendations in individuals with cardiovascular risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

4.2.1 General introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 4.2.2 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 4.2.3 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.2.4 Dyslipidaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 4.2.5 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.2.5.1 Effect of exercise on diabetic control, risk factors and outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.2.5.2 Recommendations for participation in exercise in individuals with diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.2.5.3 Cardiac evaluation before exercise in individuals with diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 4.3 Exercise and sports in ageing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 4.3.2 Risk stratification, inclusion/exclusion criteria . . . . . . . . . . . . . 37 4.3.3 Exercise modalities and recommendations for exercise and sport in the elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 5 Exercise in clinical settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.1 Exercise programmes for leisure-time and competitive sport participation in chronic coronary syndrome . . . . . . . . . . . . . . . . 38

5.1.1 Individuals at risk of atherosclerotic coronary artery disease and asymptomatic individuals in whom coronary artery disease is detected at screening . . . . . . . . . . . . . . . . . . . . . . . . . 39 5.1.1.1 Recommendations for sports participation . . . . . . . . . . . 39 5.1.2 Established (long-standing) chronic coronary syndrome . . . 40 5.1.2.1 Antithrombotic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.3 Myocardial ischaemia without obstructive disease in the epicardial coronary artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.4 Return to sport after acute coronary syndrome . . . . . . . . . . 42 5.1.4.1 Competitive athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.4.2 Recreational athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.5 Anomalous origin of coronary arteries . . . . . . . . . . . . . . . . . . . 42 5.1.5.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.5.2 Eligibility for sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 5.1.6 Myocardial bridging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 5.1.6.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 5.1.6.2 Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 5.2 Exercise recommendations in individuals with chronic heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

5.2.1 Background: rationale for exercise in chronic heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 5.2.2 Risk stratification and preliminary evaluation . . . . . . . . . . . . . . 44 Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026