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............................................................................................................................................................................. 5.4.5 Recommendations Regular exercise has a well-documented benefit for fitness, psychological well-being, and social interaction, as well as a positive effect on hypertension and concomitant future risk of dissection. Most individuals with aortic pathology benefit from a certain minimal exercise programme and can at least participate in recreational sports (Table 14). Some lesions are not compatible with endurance training and athletic sports, due to their high risk of dissection or rupture. Recommendations for exercise and sports should be individualized and based on the underlying diagnosis, the aortic diameter, family history for dissection or sudden death (risk factor), and the pre-existing fitness and experience. An exercise test with an assessment of blood pressure response is recommended before engaging in sports.

5.5 Exercise recommendations in

individuals with cardiomyopathies, myocarditis, and pericarditis Cardiomyopathies are an important cause of SCD/SCA in young individuals and exercise has been implicated as a trigger for fatal arrhythmias.1719,28 The detection of a cardiomyopathy in an individual has important implications with respect to ongoing participation in exercise. The advent of preventive strategies for SCD has led to a significant expansion in the number of predominantly asymptomatic young patients with cardiomyopathies who aspire to exercise. When advising such individuals, it is essential to strike a balance between protecting patients from the potentially adverse effects of exercise and depriving them of the multiple benefits of exercise. 5.5.1 Hypertrophic cardiomyopathy The diagnosis of HCM is based on the presence of unexplained LV hypertrophy, defined as a maximum end-diastolic wall thickness >_15 mm, in any myocardial segment on echocardiography, CMR, or CT imaging.355 HCM may also be considered in individuals with a lesser degree of LV hypertrophy (wall thickness >_13 mm) in the context of a family history of definite HCM or a positive genetic test.355

5.5.1.1 Risk stratification in hypertrophic cardiomyopathy Circumstantial evidence and a large systematic collection of young SCDs in sports in the US suggest that exercise increases the risk of SCD/SCA in individuals with HCM.18 Consistently, previous consensus recommendations have restricted all athletes with HCM from competitive sports.1,356,357 More recently, relatively small longitudinal clinical studies indicate that the risk of SCD during exercise may be considerably lower than initially considered. Lampert et al. reported that individuals with HCM who continued participating in sports after implantable cardioverter defibrillator (ICD) implantation did not reveal an increased number of shocks during exercise.358,359 In a cross-sectional study of 187 patients with HCM, vigorous exercise was not associated with the occurrence of VAs.358 Pelliccia et al. reported outcomes in a cohort of 35 athletes with HCM, engaged in training and competitions for 5 to 31 years (mean 15 ± 8). During a 9-year follow-up period, there were no differences in the incidence of symptoms or major events between athletes who ceased exercise (n = 20) compared with athletes who continued competitive sports (n = 15).360 In a post-mortem series, only 23% of 194 deaths from HCM occurred during sport, and affected males with a mean age of 30 years.361 Finally, individuals with HCM who participated in rehabilitation programmes demonstrated a significant improvement in functional capacity without adverse events.362,363 In conclusion, there is limited evidence to indicate that all individuals with HCM are vulnerable to fatal arrhythmias during exercise and sport participation. In this regard, systematic restriction from competitive sports in all affected individuals is probably unjustified and a more liberal approach to sports participation is reasonable in some individuals after careful evaluation.3 This is particularly important for the majority of individuals with HCM who wish to participate in amateur sports or leisure-time exercise to maintain their physical and psychological well-being.

5.5.1.2 Baseline assessment of patients with HCM A systematic approach is required when assessing an individual with HCM who requests exercise advice. The baseline evaluation should include a comprehensive personal and family history with consideration of the age of the individual and years of exercise prior to diagnosis, assessment of the severity of the HCM phenotype, and the presence of any conventional risk factors for SCD/SCA. In older patients with HCM, the physician should review the presence of cardiac comorbidities such as hypertension and ischaemic heart disease, which may confer a worse prognosis in HCM.364,365

5.5.1.3 History The presence of symptoms attributed to HCM should prompt more conservative exercise recommendations. Individuals with a history of cardiac arrest or unheralded syncope and individuals with exercise-

Recommendations for exercise and participation in sports in individuals with aortic pathology

Recommendations Classa Levelb

Prior to engaging in exercise, risk stratification, with careful assessment including advanced imaging of the aorta (CT/CMR) and exercise testing with blood pressure assessment is recommended. I C Regular follow-up including risk assessment is recommended. I C Dynamic exercise should be considered more suitable than static exercise. IIa C Participation in competitive or leisure-time sports activities (except power sports) should be considered in low-risk individuals (Table 14). IIa C Participation in individualized leisure exercise programmes may be considered in high-risk individuals (Table 14). IIb C Competitive sports are not recommended in individuals who are at high risk (Table 14). III C

CMR = cardiac magnetic resonance; CT = computed tomography. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026