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............................................................................................................. which can be rapidly fatal. Advanced age, male sex, long-term history of arterial hypertension, and the presence of aortic aneurysm confer the greatest population attributable risk for aortic dissection. However, patients with genetic connective tissue disorders such as Marfan (MFS), Loeys Dietz, Turner, or Ehlers Danlos (EDS) syndromes, and patients with BAV are at increased risk at a much younger age. BAV has a prevalence of about 12% in the general population. These patients have a relatively low risk for aortic dissection in comparison with patients with hereditary thoracic aortic disease (HTAD). Having a family history of aortic dissection or sudden death is a risk factor and a larger diameter of the aorta carries a higher risk, although dissection can occur at any diameter and especially in EDS patients there is no clear association with aortic diameter.341343

A dilated aortic root (>40 mm) is not a feature of athlete’s heart, with only a small minority of young athletes (0.3%) having an enlarged aortic root diameter.344347 During follow-up no progressive enlargement of the aortic diameter was observed in these athletes, and no aortic events occurred during a 5-year period.347

5.4.2 Risk of dissection Because of the increase in BP and wall stress associated with intensive exercise and sports, such activities are potentially associated with an enhanced risk of expansion of the aorta and acute aortic dissection. However, daily exercise is important in maintaining an ideal BP, heart rate, and body weight and a sedentary lifestyle is an important modifiable risk factor for CV disease and mortality. Physical activity is advised in all patients with aortic pathology, even when the aorta is dilated. There are no randomized controlled trials on competitive sports in patients with thoracic aortic disease, or any prospective data regarding the risks of competitive athletics in patients after surgical correction; however, even after aortic root replacement, patients with MFS and other HTAD remain at risk of aortic complications. One small prospective cohort study evaluated the feasibility and effects of a 3-week rehabilitation training programme in 19 MFS patients with a mean age of 47 years. During the 1-year follow-up, there were no adverse events but there was improvement in physical fitness and reduction in psychological distress. These effects were detectable after 3 weeks of rehabilitation, and mostly persisted through the 1-year follow-up. Unfortunately, no information on aortic diameters was provided.348

5.4.3 Sporting disciplines Exercise-related acute thoracic aortic dissections are described in the literature in a total of 49 case reports. Of these, 42 patients suffered Stanford type A thoracic aortic dissections. In the majority (26/ 49) weightlifting was associated with aortic dissection.349 Furthermore, a recently published retrospective cohort study of 615 patients with acute type A aortic dissection found that 4.1% cases were related to sports activities. The type of sports most often reported was golf (32%), but this was not corrected for the percentage of participants in the sport and probably reflects that golfers are frequently older with an increased risk of hypertension and hence the potential for dissection.350

5.4.4 Effect on aortic diameter and wall stress One cross-sectional study, which included 58 competitive athletes with BAV, showed no correlation between aortic dimensions and duration of training.351 Two studies compared athletes and sedentary individuals with BAV and reported no difference in aortic growth rate between the two groups. Two MFS mouse models investigating the effects of mildmoderate dynamic exercise on the aortic wall showed a reduction in the growth rate of the aortic diameter in mice with MFS that performed mild to moderate dynamic exercise compared to sedentary mice with MFS.352,353 Among exercising mice, the aortic wall became stronger and a larger mechanical stress was required to induce aortic rupture. An optimum protective effect was found at a training intensity level of 5565% of maximum oxygen uptake (VO2max).

Table 14 Classification of risk to perform sports in patients with aortic pathology

©ESC 2020

ASI = aortic size index; BAV = bicuspid aortic valve; HTAD = hereditary thoracic aortic disease; MFS = Marfan syndrome. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026