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................................................................................................................................................ 5.6.7 Following device implantation 5.6.7.1 Pacemakers Pacemaker (PM) implantation is common. Generally, individuals implanted with a PM have less severe disease and comorbidities than patients with an ICD. Moreover, there is less risk of malfunction for a PM than for an ICD during sports.552 For all these reasons, recommendations for sports practice are more liberal in patients with a PM than in patients with an ICD. Patients with a PM may participate in competitive or recreational sports in the absence of structural or other heart disease for which exercise may be prohibited.

In the first weeks after device implantation, sports activities that increase the risk of lead dislocation (e.g. strong upper extremity movements) should be avoided. Exercise testing and/or Holter monitoring during sports may improve individualized programming of the upper sensor and the tracking rate and exclude inappropriate rate acceleration in other circumstances (e.g. horse riding).553 For all patients with cardiac devices (PM, cardiac resynchronization therapy, and ICD), sports activities associated with a risk of chest trauma should be avoided.554557 Some sports such as soccer, basketball, and baseball may be possible while wearing appropriate padding. It is noteworthy that sports with pronounced arm movements such as volleyball, basketball, tennis, golf, and climbing may increase the risk for late lead damage due to subclavian crush (with insulation or conductor failure).554,558,559 Implantation on the contralateral side of the dominant arm, fixation within the pocket, or submuscular placement may improve durability of the system. It is not known whether subcostal or epicardial implant techniques provide longterm benefit. Electromagnetic interference is unlikely with modern devices, and no cases have been reported, but it should always be suspected and closely evaluated in specific athletic environments with electronic equipment (e.g. fencing). Myopotential inhibition may result in inhibition of pacing, a problem that is more common with unipolar electrodes, although it can usually be corrected with appropriate reprogramming of the device.560,561 Bipolar leads are less sensitive to this problem, but may have a reduced longevity.

5.6.7.2 Implantable cardioverter defibrillators A large multinational ICD Sports Safety Registry has shown that after a median follow-up of 44 months, there were no deaths or arrhythmia or shock-related physical injury in 440 athletes who continued organized competitive or high-risk sports after ICD implantation.359,389 An additional analysis in 82 non-professional recreational athletes confirmed these reassuring outcomes,562 which is relevant for the many ICD recipients who want to continue recreational sports activities after implantation. Therefore, shared decision making is appropriate when deciding whether or not to continue sports and the level of participation with an ICD. However, three important considerations come into play. First, if sport is contraindicated because it can contribute to the progression of the underlying disease (such as in arrhythmogenic cardiomyopathy or lamin A/C mutations),384,425 an ICD cannot be considered as a substitute for sports restriction, and participation in moderate- and high-intensity exercise should be discouraged. Recommendations in such circumstances should have a lifetime perspective and be based on the optimal preservation of structural cardiac integrity. The ICD, however, may allow for light to moderate exercise without concerns about risk of arrhythmia or shocks, and may help individuals to regain autonomy and overcome fears relating to exercising unattended.

The second consideration is that ICD shocks in general, even when appropriate and safe, will have a psychological impact on the athlete; 3040% of the athletes who experienced shocks in the multinational ICD Sports Safety Registry stopped participation, at least temporarily, out of fear of repeat shocks.389 Moreover, the proportion of athletes with appropriate and inappropriate shocks during exercise was higher in competitive than in recreational sports, emphasizing the known triggering effect of high-intensity exercise.562 Considering that ICD therapy is lifelong, where quality of life is not only dependent on the ability to perform sports activities, but also and mostly on continued trust in the device, physicians should be aware that their own belief in the effectiveness and safety of ICD therapy during sports should not implicitly put pressure on the athlete to continue sports. Again, informed decision making needs to reevaluate all options of the athlete aftershocks, including continuing, reducing, or stopping sports.563,564 Third, situations where loss of focus or loss of consciousness could cause harm to a third party or the athlete (such as in motor sports, diving, mountain climbing, even cycling) should be avoided. The athlete must be aware of the programmed detection rate cutoffs to be able to avoid reaching those during exercise. Conversely, detection zones need to be programmed sufficiently high to allow for adequately high heart rates during the desired exercise levels. This practice proved safe and reduced the occurrence of shocks in the ICD Sports Safety Database.565 The most common cause of inappropriate shocks in individuals with an ICD is the occurrence of sinus tachycardia and supraventricular arrhythmias.566,567 Underlying heart disease and endurance sport itself carries a higher risk for developing AF.474,480,568 Implantation of a dual system ICD for the sole reason of atrial arrhythmia detection and discrimination is not warranted because it is usually not effective.565,569572 Given the fact that many of these athletes are young, there is a higher risk for long-term lead complications when more leads are implanted; therefore, implantation of more complex ICD systems, and their indication, should be weighed in every patient. Routine inclusion of athletes in remote monitoring programmes is highly recommended. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026