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............................................................................................................................................................................. is recommended in this age group, although one study499 suggested that prophylactic assessment and ablation reduces the risk of sudden death. There is a knowledge gap in the benefit/risk ratio of this approach and large-scale studies are required to address the issue.

Leisure-time and low- to medium-intensity exercise programmes can generally be resumed 1 week after ablation if there is no particular risk of recurrence of arrhythmia. Resuming competitive sports is possible after 13 months, with further ECG follow-up at 6 months and 1 year (given the very small risk for late recurrence of pre-excitation). Although there may be an association between (type of) AVNRT and history of sports, there are no data about higher recurrence rate post ablation when sports are resumed or not, and hence no reason to limit exercise programmes for such reason.

5.6.4 Premature ventricular contractions and non-sustained ventricular tachycardia 5.6.4.1 Relation between number of premature ventricular contractions and risk Only a minority of athletes exhibit frequent or complex VA with a prevalence similar to that of their sedentary counterparts.502505 Premature ventricular contractions (PVCs) may be a marker of underlying heart disease, the presence of which would confer an unfavourable prognosis even in asymptomatic individuals. Specific characteristics of the PVCs, including morphology (origin from the apex or free wall of the LV or RV), high burden, complexity (e.g. couplets, triplets, or non-sustained runs), multifocal origin, and/or increasing frequency with exercise should alert to the possibility of electrical, ischaemic, or structural heart disease.505,506

There is no absolute threshold of the number of PVCs that can be used as a cut-off for underlying disease. One study has shown that in asymptomatic athletes with >2000 PVCs per day, there was a 30% chance of finding an underlying structural or cardio-genetic disease.503

5.6.4.2 Morphology of premature ventricular contractions The morphology of the PVCs may provide important prognostic information since some foci of origin are recognized as benign. The most prevalent entity in this respect are PVCs originating from the right or left ventricular outflow regions (RVOT/LVOT), showing a clear inferior axis with high voltages in the inferior limb leads. Early precordial transition (in V2, and certainly when V1 shows a right bundle branch morphology) suggests a left-sided origin.507 RVOT/LVOT PVCs are thought to be the result of triggered activity, i.e. a local cellular cause, which has no negative prognostic implications. Although these RVOT/LVOT arrhythmias usually occur in structurally normal hearts, they may be the expression of subclinical arrhythmogenic cardiomyopathy. Cardiac imaging tests can help exclude structural heart disease in such athletes. Less common locations of focal PVCs are around the mitral or tricuspid annulus, most often in a postero-septal location. These have a superior axis with LBBB or RBBB morphology. The PVCs originating from the His-Purkinje system typically have relatively narrow QRS complex with RBBB morphology and either left anterior or left posterior hemi-block. Lastly, intramyocardial foci may occur, often related to the papillary muscles or moderator band.508 PVCs of differing morphologies from the RV (i.e., wide LBBB and superior axis) in individuals with normal LV function should prompt investigations to exclude arrhythmogenic cardiomyopathy or sarcoidosis. Similarly, wide RBBB pattern, with superior axis and multifocal PVCs of LV origin should trigger investigations for non-ischaemic cardiomyopathy. Very rarely, otherwise ‘benign’ PVCs arising from the Purkinje network may give rise to polymorphic ventricular tachycardia (VT) or VF due to their short coupling interval.509,510 In such patients, the malignant electrical presentation mandates aggressive treatment. Finally, frequent but otherwise benign PVCs (usually defined as >1015% of the total number of beats per 24 h) can impair LV function over time (PVC-induced cardiomyopathy), which may be reversible with medical treatment or catheter ablation.511,512

5.6.4.3 Premature ventricular contractions: response to exercise Reduction or resolution of PVCs with increasing exercise load is typical of idiopathic and benign VAs, particularly those with an outflow tract morphology.513,514 PVCs induced by exercise should be considered as a ‘red flag’, because VAs associated with heart diseases are often made worse by adrenergic stimulation.19,502,511,512,515520 A higher prevalence of myocardial substrates (mainly mid-wall or subepicardial non-ischaemic LV scars) was found in a CMR study among athletes with exercise-induced PVCs compared to those with exercise-suppressed VAs (56% vs. 21%).516

Recommendations for exercise and sports participation in individuals with paroxysmal supraventricular tachycardia and pre-excitation

Recommendations Classa Levelb

In individuals with palpitations, a comprehensive assessment to exclude (latent) pre-excitation, structural heart disease, and VAs is recommended.500 I B Participation in all sports activities is recommended in individuals PSVT without preexcitation.500 I C Ablation of the accessory pathway is recommended in competitive and recreational athletes with pre-excitation and documented arrhythmias.500 I C In competitive/professional athletes with asymptomatic pre-excitation, an EP study is recommended to evaluate the risk for sudden death.497,500 I B In competitive athletes with PSVT but without pre-excitation, curative treatment by ablation should be considered. IIa C

EP = electrophysiological; PSVT = paroxysmal supraventricular tachycardia; 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