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................................................................................................. volume and cardiac preload as a consequence of hydrostatic pressure may not be tolerated.283 However, a recent meta-analysis has shown that aquatic exercise training may be safe and clinically effective.284

5.2.4 Sports participation and return to sports In addition to risk stratification (section 5.2.3), the evaluation for participation in sports includes intensity and type of sports (competitive vs. recreational), and determining the individual fitness level.

5.2.4.1 Competitive sports Participation in competitive sports may be considered in a group of selected low-risk individuals. A thorough individual evaluation using a maximal exercise test (or preferably CPET) is recommended before returning to sports, particularly before starting moderate- to high-intensity sports, mixed and power sports (Figure 2, section 4.1.2). Asymptomatic individuals with preserved (>_50%) EF (HFpEF) or with mid-range (>_4059%) EF (HFmrEF) who are optimally treated may be eligible to participate in some competitive sports in the absence of exercise-induced arrhythmias or exercise-induced hypotension. In such cases, a progressive increase in exercise dose is recommended. The duration of this process is dependent upon the functional capacity and perceived symptoms. Some restrictions may apply to high-intensity endurance, mixed and power sports with high demands, especially in older patients. No restrictions should apply for skill-related sports.

Asymptomatic patients with HFrEF who are optimally treated may only be considered safe to perform specific low-intensity skill sports at a competitive level (Figure 2). Higher-risk patients including those who are suboptimally treated, those that remain in NYHA II or III despite optimal therapy, and those with exerciseinduced arrhythmias or exercise-induced hypotension should not participate in competitive sports, particularly those sports with moderate to high cardiopulmonary strain during training or competition.

5.2.4.2 Recreational sports For patients intending to participate in recreational sports and leisure-time activity, similar principles apply regarding risk stratification. A progressive increase in exercise dose is recommended. Lowto moderate-intensity skill, power, mixed, and endurance sports may be considered in all asymptomatic individuals. As with competitive sports, high-intensity recreational sports should only be considered in asymptomatic individuals with HFmrEF (EF 4049%) who do not have exercise-induced arrhythmias or exercise-induced hypotension. Asymptomatic individuals with HFrEF who are optimally treated may engage in low- to moderate-intensity skill-related recreational sports, and selectively in low-intensity endurance sports (Figure 2). In patients with HFrEF with very low exercise tolerance, frequent decompensation, or patients with LV assist devices (see Supplementary Data), participation in low-intensity skill-related sports is possible, if tolerated. Regular low-intensity endurance activities, e.g. walking or cycling, should generally be recommended to improve basic exercise capacity.

Recommendations for exercise prescription in heart failure with reduced or mid-range ejection fraction

Recommendations Classa Levelb

Regular discussion about exercise participation and provision of an individualized exercise prescription is recommended in all individuals with heart failure.260,261,285 I A Exercise-based cardiac rehabilitation is recommended in all stable individuals to improve exercise capacity, quality of life, and to reduce the frequency of hospital readmission.260,261,285 I A Beyond annual cardiac assessment, clinical reassessment should be considered when the intensity of exercise is increased. IIa C Motivational and psychological support and individualized recommendations on how to progress the amount and intensity of sports activities should be considered. IIa C Low- to moderate-intensity recreational sporting activities and participation in structured exercise programmes may be considered in stable individuals. IIb C High-intensity interval training programmes may be considered in low-risk patients who want to return to high-intensity aerobic and mixed endurance sports. IIb C

aClass of recommendation. bLevel of evidence. Recommendations for participation in sports in heart failure

Recommendations Classa Levelb

Before considering a sport activity, a preliminary optimization of heart failure risk factor control and therapy, including device implantation (if appropriate), is recommended. I C Participation in sports activities should be considered in individuals with heart failure who are at low risk, based on a complete assessment and exclusion of all contraindications, in stable condition for at least 4 weeks, optimal treatment, and NYHA functional class I status. IIa C Non-competitive (low- to moderate-intensity recreational) skill, power, mixed, or endurance sports may be considered in stable, asymptomatic, and optimally treated individuals with HFmrEF. IIb C High-intensity recreational sports, adapted to the capabilities of the individual patient, may be considered in selected stable, asymptomatic, and optimally treated individuals with HFmrEF with an age-matched exercise capacity beyond average. IIb C

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