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5.1.3 Myocardial ischaemia without obstructive disease in the epicardial coronary artery Ischaemia and non-obstructive CAD (INOCA) is an underrecognized entity associated with increased risk of adverse events242 that is usually detected during evaluation of anginal symptoms. Stress CMR and PET can detect abnormal coronary flow reserve and suggest coronary microvascular dysfunction with non-critical lesions. There are no established treatments for microvascular angina. However, the panel suggests adhering to the same exercise recommendations as for long-standing CCS.

5.1.4 Return to sport after acute coronary syndrome Exercise-based cardiac rehabilitation (exCR) reduces cardiac mortality, hospital readmission,234234 and anxiety.243 Individuals who have experienced an ACS, cardiac surgery, or percutaneous intervention should be referred to an early exCR programme,235,242 soon after the discharge,6,235,244 for 812 weeks after the cardiac event.235,244 Every week that exercise is delayed requires an additional month of exercise to accomplish the same level of benefit.245 Exercising individuals with CAD may start performing low- to moderate-intensity recreational sporting activities in parallel with participation in the structured progressive exercise programmes. All types of sports activities may be considered, at an appropriate intensity level; however, careful attention should be paid to the development of new symptoms.218 In general, structured outpatient exercise programmes, for 36 months, are required to achieve the appropriate level of activity for sports participation in patients with CAD. In individuals with non-ST segment elevation MI or CCS who have had complete revascularization and do not have residual ischaemia, exercise training can be progressed at a faster pace until the recommended exercise level is reached.

5.1.4.1 Competitive athletes Careful individual evaluation is required before starting high-intensity competitive sports. In competitive athletes, an echocardiogram, maximal exercise test with 12-lead ECG recording or CPET is recommended for risk stratification before return to sports (see section 5.1.2). CPET specifically adds information on aerobic and anaerobic thresholds, guiding exercise intensity prescription and progression (see section 4.2).

5.1.4.2 Recreational athletes For individuals intending to participate in non-competitive, recreational sports and leisure-time activity, similar principles apply regarding risk stratification. A symptom-limited/maximal exercise test should precede the return to sports. Higher-risk patients with CCS (Table 11) are not eligible for competitive sports (see section 5.1.2); however, low-intensity skill sports, such as golf, may be considered, at intensities below the angina threshold. If aerobic exercise is not tolerated, predominantly strength-related sports with a small amount of muscular work are recommended (Figure 2, section 4.1.2). 5.1.5 Anomalous origin of coronary arteries 5.1.5.1 Background The prevalence of AOCA (left and right coronary artery) is 0.44% in the general population of adolescents.246 AOCA is considered to be a common cause of SCD in young athletes17,18,247,248 but is rarely implicated in individuals >40 years of age.249,250

Chest pain, exertional syncope and SCD may be the first manifestation of AOCA,251 however, over two thirds of patients are asymptomatic.252 Mechanisms leading to SCD likely include repeated bursts of ischaemia with consequent increase in myocardial fibrosis and a proclivity to develop VAs during exercise. Ischaemia may result from the compression of the anomalous vessel coursing between the aorta and the pulmonary artery and/or from the acute angled take-off from the aorta and/or the proximal intramural course of the anomalous vessel (Figure 6).253 Both left and right anomalous coronary origins have been implicated in Ex- R SCD, although the risk has traditionally been thought to be considerably higher with an anomalous left coronary artery origin.252 Exercise testing rarely reveals myocardial ischaemia and multislice contrast-enhanced CT, CCTA, or CMR are the mainstay of diagnosis.

5.1.5.2 Eligibility for sports Eligibility for competitive sports is based on the anatomical type of AOCA and on the presence of ischaemia. A highly positive inotropic and positive chronotropic exercise stress test is the best approach to demonstrate or rule out ischaemia. AOCA with acute angled take-off from the aorta resulting in a slit-like orifice with reduced lumen and anomalous coursing between the aorta and the pulmonary artery is associated with the greatest risk for SCA/SCD whether or not the anomalous artery originates from the left or right sinus of Valsalva, and strong consideration should be given to surgical correction of such an anomaly

Recommendations for return to exercise after acute coronary syndrome

Recommendations Classa Levelb

Exercise-based cardiac rehabilitation is recommended in all individuals with CAD to reduce cardiac mortality and rehospitalization.234 I A During the initial period, motivational and psychological support, and individualized recommendations on how to progress the amount and intensity of sports activities, should be considered in patients with CAD. IIa B All sports activities should be considered, at an individually adapted intensity level in low-risk individuals with CCS. IIa C

CAD = coronary artery disease; CCS = chronic coronary syndrome. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026