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................................................................................................... presentation, large pericardial effusion, and those who are resistant to therapy with non-steroidal anti-inflammatory drugs.465,466 5.5.6.3 Exercise recommendations for individuals with pericarditis Exercise should be avoided in individuals during active pericarditis. Individuals can return to exercise after complete resolution of the active disease.467 Individuals with a milder clinical course and rapid resolution can return to sporting activities within 30 days. However, in more severe cases, it may be necessary to wait for a period of 3 months for complete resolution followed by re-evaluation before returning to sports. Asymptomatic individuals with a small pericardial effusion occasionally detected on echocardiography in the absence of clinical correlates should be monitored with periodic surveillance, but should not be restricted from sports participation. Competitive sports and/ or moderate- to high-intensity leisure-time activities should be avoided in individuals with constrictive pericarditis. Individuals with myopericarditis should be managed according to the recommendations for myocarditis. 5.6 Exercise recommendations in individuals with arrhythmias and channelopathies 5.6.1 A general management framework When individuals with known arrhythmias or with a potentially arrhythmogenic condition want to engage in sports activity, three principle questions should guide management: (1) is there an increased risk for life-threatening arrhythmias?; (2) how does one control symptoms due to arrhythmias, during sports, but also at rest?; and (3) what is the impact of sports on the natural progression of the arrhythmogenic condition? The general view on the association between sports and arrhythmias is that exercise sets the stage for an arrhythmia in the context of an underlying and pre-existing condition, be it structural, electrical, inherited, or acquired. Moreover, regular exercise programmes may induce or accelerate the progression of ARVC,382,384 even among those without underlying mutations.383,387,468 Conceptually, all the structural and functional cardiac adaptations to regular intensive exercise may contribute to the development of arrhythmias, at the atrial, nodal, and ventricular level.469 This concept explains why recommendations for sports participation in individuals with arrhythmogenic conditions are so complex. 5.6.2 Atrial fibrillation 5.6.2.1 Patients without atrial fibrillation Moderate, regular PA is a cornerstone in the prevention of AF through modifying many of its predisposing factors.297,470473 Patients at risk of AF should therefore be motivated to exercise (see section 4.2). Conversely, AF is more prevalent in active and former male master athletes and those performing high-intensity endurance sports, suggesting a U-shaped relationship between habitual exercise and AF.471,474477 478481 This association has not been confirmed in women.474 Recommendations for exercise in individuals with myocarditis Recommendations Classa Levelb Comprehensive evaluation, using imaging studies, exercise stress test and Holter monitoring, is recommended following recovery from acute myocarditis to assess the risk of exercise-related SCD.455,462,463 I B Return to all forms of exercise including competitive sports should be considered after 36 months in asymptomatic individuals, with normal troponin and biomarkers of inflammation, normal LV systolic function on echocardiography and CMR, no evidence of ongoing inflammation or myocardial fibrosis on CMR, good functional capacity, and absence of frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing.430,434,453,459,460,464 IIa C Among individuals with a probable or definitive diagnosis of recent myocarditis, participation in leisure-time or competitive sports while active inflammation is present is not recommended.459,460 III C Participation in moderate- to high-intensity exercise for a period of 36 months after acute myocarditis is not recommended.459461,467 III B Participation in leisure exercise or competitive sports involving high intensity in individuals with residual myocardial scar and persistent LV dysfunction is not recommended. III C CMR = cardiovascular magnetic resonance; LV = left ventricular; SCD = sudden cardiac death; VA = ventricular arrhythmia. aClass of recommendation. bLevel of evidence. Recommendations for exercise in individuals with pericarditis Recommendations Classa Levelb Return to all forms of exercise including competitive sports is recommended after 30 days to 3 months for individuals who have recovered completely from acute pericarditis, depending on clinical severity.459,460 I C Participation in leisure-time or competitive sports is not recommended for individuals with a probable or definitive diagnosis of recent pericarditis while active inflammation is present, regardless of age, sex, or extent of LV systolic dysfunction.459,460 III C Participation in moderate- to high-intensity exercise, including competitive sports, is not recommended for individuals with constrictive pericarditis. III C LV = left ventricle. aClass of recommendation. bLevel of evidence. 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