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5.7 Exercise recommendations in

individuals with adult congenital heart disease 5.7.1 Introduction Congenital heart disease (CHD) has a prevalence of 89 per 1000 live births and is the most common birth defect.573 Most children with CHD survive to adulthood, including over 85% with complex disease. Regular exercise is important for adults with congenital heart disease (ACHD) and exercise participation should be discussed at every patient encounter.574 However, CHD represents a spectrum of conditions with widely varying physiological consequences. Individualized assessment is essential before advising on sports participation. This requires detailed understanding of the congenital heart defect, its physiological consequences, and the effect of surgical or transcatheter intervention.

5.7.2 The increasing numbers of athletes with congenital heart disease Athletes with CHD include those with minor unoperated lesions and palliated and repaired CHD. Some athletes will be diagnosed with CHD for the first time during pre-participation screening. Approximately 1 in 150 adults have a congenital heart defect. This is an increase of over 50% in the last 10 years and reflects improved diagnosis and long-term survival.575 Overall 90% of adults with CHD are in NYHA functional class I or II.576 The number of professional and recreational athletes with CHD is unknown but the elite athlete population is likely to be small. In a study of 2352 Olympian athletes, only nine (0.4%) had a congenital heart defect.577 However, many more CHD patients compete at a recreational level. It is likely that the number of athletes with CHD is increasing due to improved survival, better understanding of the benefits of exercise, and the increased number of professional athletes from countries where poorly developed healthcare systems are associated with under-diagnosis of CHD.573,574

5.7.3 Non-cardiac abnormalities in congenital heart disease and Paralympic sport CHD has a multifactorial aetiology, but there is a significant genetic component and a recurrence risk of 25%.578 The genetic origin may be due to a chromosome anomaly, a heritable syndrome with Mendelian pattern, or sporadic with variable penetrance.578 Approximately 14% of patients with CHD have additional noncardiac abnormalities.579 Thus, 44% of ACHD patients have lung function abnormalities.580 This can make advising sports participation for the ACHD athlete more difficult. There is no specific classification for CHD in Paralympic sport.

5.7.4 General considerations in the congenital heart disease athlete There is considerable variation in the haemodynamic consequences and prognosis of different CHD lesions. Furthermore, the consequences of any individual lesion can vary hugely between individuals. Thus, Ebstein’s anomaly may present in infancy with pulmonary hypoplasia due to compression by a giant right atrium or may present in late middle age with supraventricular tachycardia and minimal haemodynamic consequences. Similarly, a ventricular septal defect may be small and asymptomatic, or large presenting with HF in infancy, or may present with extreme cyanosis, reduced exercise capacity, and Eisenmenger syndrome in the adult. Consequently, these recommendations are based on a physiological assessment rather than underlying anatomic diagnosis. An understanding of the range of severity and a lesion-based knowledge of potential complications is essential. The cardiologist should work in conjunction with a CHD specialist. Athletes with CHD who participate in regular training and competitive sports should undergo a comprehensive annual assessment that includes clinical examination, ECG, echocardiogram, and exercise stress test, ideally CPET. Many athletes with CHD will have undergone corrective or palliative surgery. In young adults with post-surgical CHD, valve

Recommendations for exercise in individuals with pacemakers and implantable cardioverter defibrillators

Recommendations Classa Levelb

It is recommended that individuals with implanted devices with/without resynchronization and underlying disease follow the recommendations pertaining to the underlying disease.384,425 I B Participation in sports and exercise (except collision sports) should be considered in individuals with pacemaker therapy who do not have pathological substrates for fatal arrhythmias. IIa C Prevention of direct impact to the implanted device by adapting the site of lead and/or device implantation, padding, or restricting direct impact sports should be considered. IIa C Holter recordings and device interrogation during and after resuming sports should be considered to allow appropriate tailoring of rateresponsive pacing parameters, exclusion of myopotential or electromagnetic inhibition, and detection of VAs. IIa C Shared decision making should be considered during decisions relating to continuation of intensive or competitive sports participation in individuals with an ICD, taking into account the effect of sports on the underlying substrate, the fact that intensive sports will trigger more appropriate and inappropriate shocks, the psychological impact of shocks on the athlete/patient, and the potential risk for third parties. IIa C An ICD is not recommended as a substitute for disease-related recommendations when these mandate sports restrictions. III C

ICD = implantable cardioverter defibrillator; 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