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Specifically, the presence of LGE, with the typical mid-wall distribution, has been associated with increased risk of VAs and SCD.319,419,421424

5.5.4.1 Baseline assessment of patients with dilated cardiomyopathy Clinical evaluation of affected individuals who request exercise advice should aim to: (i) ascertain the potential aetiology; (ii) assess the clinical status including exercise history and functional capacity; (iii) review the degree of LV dilatation and dysfunction; (iv) assess the haemodynamic response to exercise; and (v) assess the presence of exercise-induced symptoms or arrhythmias. In general, symptomatic individuals with DCM should abstain from most competitive and leisure sports or recreational exercise associated with moderate or high exercise intensity. A select group of asymptomatic individuals with DCM who have mildly impaired LV function (LVEF 4550%) without exercise-induced arrhythmias or significant myocardial fibrosis may participate in most competitive sports.

5.5.4.2 Special considerations Although the natural history of most pathogenic variants is unknown, it would be reasonable to permit intensive exercise and competitive sports in most individuals with pathogenic variants implicated in DCM in the absence of overt features of DCM. Special consideration, however, should be given to individuals with pathogenic variants that are associated with an increased risk of life-threatening arrhythmias such as lamin A/C or filamin C mutations. There is emerging evidence that exercise may have an adverse effect on cardiac function and risk for potentially fatal arrhythmias in individuals harbouring pathogenic variants in lamin A/C.425427 Affected individuals should not engage in any competitive sports or recreational exercise of high or very high intensity irrespective of the severity of LV dysfunction and dilatation.428,429

5.5.4.3 Follow-up. Regular follow-up is recommended for most individuals with DCM. New symptoms should prompt interruption of exercise and re-evaluation 5.5.5 Exercise recommendations in individuals with myocarditis and pericarditis 5.5.5.1 Myocarditis Myocarditis is a non-ischaemic inflammatory disease of the myocardium, which may cause cardiac dysfunction and arrhythmias. Myopericarditis is defined as a primary pericarditis with associated myocardial inflammation and biomarker evidence of myocyte necrosis.430,431 The aetiology of myocarditis is heterogenous, but viral infection is the most common cause in the developed world. Enterovirus, Coxsackie B virus, parvovirus B-19, and human herpesvirus 6 are the most frequently responsible infectious pathogens.432,433

In the context of young individuals, toxins such as cocaine and amphetamine-based supplements should also be evaluated in the clinical history.430 The clinical presentation is highly variable and the diagnosis can be challenging. The illness may be proceeded by coryzal symptoms and athletic individuals may present with non-specific features of general malaise, fatigue, or diarrhoea.430,431 At the other extreme, myocarditis may simulate MI or present with symptomatic supraventricular and VAs unexplained by other causes, HF, cardiogenic shock, or SCD. Approximately 50% of individuals reveal full resolution of LV function within 30 days, 25% show persistent cardiac dysfunction, and 1225% progress to fulminant HF. LV dysfunction is an important prognostic factor in the long term.28,434

Recommendations for exercise in individuals with dilated cardiomyopathy

Recommendations Classa Levelb

Participation in low- to moderate-intensity recreational exercise should be considered in all individuals with DCM, regardless of the EF, in the absence of limiting symptoms, and exercise-induced VAs. IIa C Participation in high- or very high-intensity exercise including competitive sports (with the exception of those where occurrence of syncope may be associated with harm or death) may be considered in asymptomatic individuals who fulfil all of the following: (i) mildly reduced LV systolic function (EF 4550%); (ii) absence of frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing; (iii) absence of LGE on CMR; (iv) ability to increase EF by 1015% during exercise; and (v) no evidence of high-risk genotype (lamin A/C or filamin C). IIb C

Continued Participation in all competitive sports may be con-

sidered in individuals with DCM who are genotype positive and phenotype negative, with the exception of carriers of high-risk mutations (lamin A/C or filamin C). IIb C Participation in high- or very high-intensity exercise including competitive sports is not recommended for individuals with a DCM and any of the following: (i) symptoms or history of cardiac arrest or unexplained syncope; (ii) LVEF<45%; (iii) frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing; (iv) extensive LGE (>20%) on CMR; or (v) high-risk genotype (lamin A/C or filamin C). III C Follow-up recommendations Annual follow-up is recommended for individuals with DCM who exercise on a regular basis. I C Six-monthly follow-up should be considered in individuals with high-risk mutations and adolescent individuals and young adults whose DCM phenotype may still be evolving and who are more vulnerable to exercise-related SCD. IIa C Annual assessment should be considered for genotype-positive/phenotype-negative individuals for phenotypic features and risk stratification purposes. IIa C

CMR = cardiac magnetic resonance; DCM = dilated cardiomyopathy; EF = ejection fraction; LGE = late gadolinium enhancement; SCD = sudden cardiac death; VA = ventricular arrhythmia. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026