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................................................................... 5.1.2 Established (long-standing) chronic coronary syndrome All individuals with established (long-standing) CCS should be encouraged to perform the minimal PA recommendations for general and CV health.235 This applies to individuals with stable angina, asymptomatic and symptomatic individuals stabilized <1 year after ACS, or individuals with recent revascularization, and asymptomatic and symptomatic individuals >1 year after initial diagnosis or revascularization.110 Advice on intensive exercise and participation in most competitive sports in asymptomatic individuals with long-standing CCS should be based on several factors, which are determined through clinical history, exercise stress testing, or functional imaging and echocardiography (Table 10). Individuals with long-standing CCS who do not show any abnormalities on a maximal exercise test or functional imaging test, or have unimpaired LV function, may be considered as low risk for an exerciseinduced adverse event236238 (Table 11). Such individuals may engage in all competitive sports on an individual basis (Figure 5). Some restrictions may apply for high-intensity power, mixed, and endurance sports (see Figure 2, section 4.1.2) for older patients (>60 years old) with CCS. This is due to the fact that age is an additional, strong predictor of adverse events during exercise. There are no restrictions in low-risk patients for skills sports regardless of age (Figure 2). Individuals with inducible ischaemia during functional testing, despite adequate treatment, should undergo coronary angiography; those with high-risk lesions on coronary angiography (Table 11) should have revascularization prior to considering high-intensity exercise programmes or competitive sport (Figure 5). Individuals with high-risk coronary features may gradually return to sport 36 months after successful revascularization pending a normal maximal exercise or functional imaging test. When ischaemia cannot be treated despite adequate therapy, including revascularization, the individual should be restricted from competitive sports, with the possible exception of individually recommended low-intensity skill sports. Such individuals may engage in regular recreational exercise of low and moderate intensity provided risk factors and symptoms are treated adequately and there is regular clinical surveillance. These individuals may also participate in leisure sports, 23 times/week, in selected cases, if the intended activity is below (around 10 beats) the ischaemic threshold and below the level of arrhythmias.231 5.1.2.1 Antithrombotic treatment Individuals with CAD should receive conventional antithrombotic treatment for secondary prevention, according to published guidelines for the general population.233,239,240 Individuals taking dual antiplatelet agents should avoid sports with bodily collision, especially when they are combined with oral anticoagulants, due to the risk of haemorrhage.241 Recommendations for exercise in individuals at risk of atherosclerotic coronary artery disease and asymptomatic individuals in whom coronary artery disease is detected at screening Recommendations Classa Levelb Among individuals with asymptomatic CCS, defined as CAD without inducible myocardial ischaemia on a functional imaging or conventional exercise stress test, 233 participation in all types of exercise, including competitive sports, should be considered based on individual assessment. IIa C CAD = coronary artery disease; CCS = chronic coronary syndrome. aClass of recommendation. bLevel of evidence. Table 10 Factors determining risk of adverse events during intensive exercise and competitive sports in asymptomatic individuals with long-standing coronary artery disease ©ESC 2020 Table 11 High-risk features for exercise-induced adverse cardiac events in patients with atherosclerotic coronary artery disease233 ©ESC 2020 ACS = acute coronary syndrome; FFR = fractional flow reserve; iFR = instant flow reserve; NSVT = non-sustained ventricular tachycardia; PCI = percutaneous coronary intervention. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026