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5.1.6 Myocardial bridging 5.1.6.1 Background Myocardial bridging (MB) refers to a condition when some of the myocardium overlies a segment of an epicardial coronary artery (referred to as a tunnelled artery) and most commonly affects the left anterior descending artery (Figure 7). The prevalence of MB varies from 0.512% and up to 575% according to diagnostic angiography or CT scan series.254 MBs are traditionally considered as benign; however, the association between myocardial ischaemia and MBs has increased their clinical relevance. MB may be discovered at imaging after an abnormal exercise ECG and should also be suspected in individuals who present with exertional angina or syncope. Coronary artery compression together with a Venturi (suction) effect are the potential underlying mechanisms for exercise-induced ischaemia.248 Evaluation of individuals with MB aims primarily at assessing the morphologic characteristics of the anatomical anomaly (i.e. number of MB, depth and overall length of the tunnelled vessel) and the presence of inducible ischaemia. A positive inotropic and positive chronotropic stress test is the best approach to demonstrate myocardial ischaemia. MB without other underlying associated diseases [e.g. hypertrophic cardiomyopathy (HCM)] and with no evidence of inducible myocardial ischaemia has a good prognosis.255 However, in adult/senior individuals, it has been shown that the arterial compression in MB may be directly related to the atherosclerotic burden, proximal to the MB.256 These individuals should be considered in the same category as individuals with CAD and treated appropriately if necessary, although the vast majority of MB is clinically silent. Betablockers should be used when patients are symptomatic or myocardial ischaemia is established. Surgical repair may be considered, while coronary stenting is discouraged.255

5.1.6.2 Eligibility Patients with MB and evidence of ischaemia should be restricted from participation in competitive sports and should receive appropriate advice regarding leisure-time activities. 5.2 Exercise recommendations in

individuals with chronic heart failure 5.2.1 Background: rationale for exercise in chronic heart failure Most of the evidence regarding exercise in chronic heart failure (HF) is derived from studies implementing exercise training programmes that are considered safe and highly recommended in stable patients on optimal medical therapy.257260Meta-analyses of these studies have demonstrated a significant improvement in exercise tolerance and quality of life and a modest effect on all-cause and HF-specific mortality and hospitalization.261267

5.2.2 Risk stratification and preliminary evaluation Exercise intervention should only be initiated in a clinically stable individual after medical therapy for HF has been optimized. Key components before commencing an exercise programme and sports participation include:

(1) Exclusion of contraindications to exercise: Contraindications to initiating an exercise programme in chronic HF include hypotension or hypertension at rest or during exercise, unstable cardiac disease, deteriorating symptoms of HF, myocardial ischaemia despite therapy (exercise may be permitted up to ischaemic threshold), or severe and suboptimally treated pulmonary disease.258 (2) Performing a baseline assessment: A thorough cardiological evaluation is required, including assessment of comorbidities and HF severity (e.g. by assessment of blood natriuretic peptides and echocardiography). A maximal exercise test (preferably CPET) is important to assess functional capacity, exercise-induced arrhythmias or haemodynamic abnormalities and for prescription of exercise intensity, based on VO2peak, or on resting and maximal heart rate during exercise [e.g. HRR or Borg’s rating of perceived exertion (RPE)].265,266 (3) Optimizing medical therapy: All individuals with HF should be treated according to current Guidelines,257 including device implantation when required.267

©ESC 2020

Figure 7 Schematic representation of a myocardial bridge. LAD = left anterior descending coronary artery. Recommendations for exercise/sports in individuals with myocardial bridging

Recommendations Classa Levelb

Participation in competitive and leisure-time sports should be considered in asymptomatic individuals with myocardial bridging and without inducible ischaemia or ventricular arrhythmia during maximal exercise testing. IIa C Competitive sports are not recommended in individuals with myocardial bridging and persistent ischaemia or complex cardiac arrhythmias during maximal exercise stress testing. III C

aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026