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....... Arrhythmias may be the first sign of underlying haemodynamic deterioration and new-onset arrhythmias should lead to a full haemodynamic assessment. Detailed guidelines for the assessment and treatment of arrhythmias in CHD are available.612 In the athlete, arrhythmia therapy may be complicated by the need to minimize the negative chronotropic effects of antiarrhythmic treatment, which may affect performance. If symptomatic arrhythmias are present then an exercise ECG, prolonged ECG monitoring, loop recorder implantation, and even electrophysiology testing might be required. This should be coordinated by an electrophysiologist with expertise in CHD. (5) Assessment of saturations/lung function CHD athletes should be assessed for the potential of an underlying intracardiac right to left shunt. This can be assessed using pulse oximetry, but a resting saturation >95% does not exclude exerciserelated central cyanosis, and exercise assessment is essential. The potential for a pulmonary cause of cyanosis must be considered and lung function should be assessed as part of a cardiopulmonary exercise test. Even after surgical correction of the cardiac defect there may be residual intracardiac shunting. Stage 3. Cardiopulmonary exercise testing CPET is invaluable in risk stratifying the adult with CHD and can predict outcome.613,614 It is also extremely useful in the evaluation of the athlete with CHD as it allows an assessment of PAP, respiratory problems, cardiac output, exercise-related haemodynamics, and arrhythmias. This should be used in conjunction with an evaluation of effort such as the Borg scale.615 Normal CPET values are available for non-athlete CHD patients.616 CPET should be carried out in conjunction with a 12-lead ECG to allow detection of arrhythmias and evaluate chronotropic incompetence. Reduced VO2max and peak oxygen pulse may reflect reduced stroke volume and are found in complex CHD as well as in other forms of CHD, including repaired tetralogy of Fallot, aortic regurgitation, and coarctation of the aorta. In CHD, ventilatory anaerobic threshold may be reduced and this impairs gas exchange efficiency in dynamic and endurance sports. This may relate to previous thoracotomy or lung disease. Similarly, there may be an elevated minute ventilation/carbon dioxide production (VE/VCO2) slope,601 indicating an inadequate pulmonary vascular bed.610,611,613616 Reduced skeletal muscle mass is common in adults with CHD and can contribute to decreased tissue oxygen uptake. The extent to which this is modified in athletes with CHD has not been evaluated. However, even in complex disease, regular resistance exercise participation improves muscle mass and regular exercise participation is a dominant factor in determining long-term outcome.593,617 Stage 4. Exercise intensity and prescription An assessment of the athlete’s sports and exercise participation should take place as discussed in the introduction (Table 16). This should include an assessment of the intensity, aerobic and resistance components (isometric and dynamic), and the overall volume of exercise, which should include training and competition. The haemodynamic consequences should be considered in light of an understanding of known lesion-specific consequences and individual athlete-specific changes identified on assessment. Stage 5. Follow-up and repeat assessment In the CHD athlete, serial assessment should be carried out—usually on an annual basis—while participating in sport. This recognizes the age-related changes that occur in the CHD athlete and the potential for onset of degenerative CVD.

6 Key messages

CV screening before participation in recreational and competitive sports is aimed at the detection of disorders associated with SCD and has the potential to lower CV risk through disease-specific and individualized patient management. CV screening in adult and senior athletes should target the higher prevalence of atherosclerotic CAD including an assessment of CVD risk factors and exercise stress test. CAC scoring may be performed in asymptomatic athletes with a moderate atherosclerotic risk profile. Healthy adults of all ages and individuals with known cardiac disease should exercise on most days, totalling at least 150 min/week of moderate-intensity exercise. Individuals with CAD, at low risk for exercise-induced adverse events, should be considered eligible for competitive or leisure sports activities, with few exceptions. Competitive sports are not recommended in individuals with CAD, at high risk of exercise-induced adverse events or those with residual ischaemia, with the exception for individually low-intensity skill sports. Exercise programmes in HF improve exercise tolerance and quality of life and have a modest effect on all-cause and HF-specific mortality, and all-cause hospitalization and HF-specific hospitalization.

Exercise recommendations for individuals with congenital heart disease

Recommendations Classa Levelb

Participation in regular moderate exercise is recommended in all individuals with CHD.588,591594,619 I B A discussion on exercise participation and provision of an individualized exercise prescription is recommended at every CHD patient encounter.574,597,598,617 I B Assessment for ventricular function, pulmonary artery pressure, aortic size, and arrhythmia risk is recommended in all athletes with CHD.342,348,573,597 I C Competitive sports participation should be considered for CHD athletes in NYHA class I or II who are free from potentially serious arrhythmias after individual tailored evaluation and shared decision making.573,595,597,598 IIa C Competitive sports are not recommended for individuals with CHD who are in NYHA class IIIIV or with potentially serious arrhythmias.605,608 III C

CHD = congenital heart disease; NYHA = New York Heart Association. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026