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............................................................................................................................................................................. Asymptomatic individuals with mild valvular heart disease may participate in all sporting activities including competitive sports.

A select group of asymptomatic individuals with moderate valve disease who have good functional capacity and no evidence of myocardial ischaemia, complex arrhythmias, or haemodynamic compromise on a maximal exercise stress test may be considered for competitive sports after careful discussion with an expert cardiologist. Implementation of healthy lifestyle behaviours including sports participation decreases the risk of CV events and mortality in individuals with aortopathies. Individuals with acute myocarditis or pericarditis should abstain from all sports while active inflammation is present. Individuals with cardiomyopathy or resolved myocarditis or pericarditis, who wish to participate in regular sports, should undergo comprehensive evaluation, including an exercise test, to assess the risk of exercise-induced arrhythmias. Individuals who are genotype positive/phenotype negative or have a mild cardiomyopathy phenotype and absence of symptoms or any risk factors, may be able to participate in competitive sports. A notable exception is arrhythmogenic cardiomyopathy where highintensity exercise and competitive sports should be discouraged. Managing sports participation in individuals with arrhythmogenic conditions is guided by three principles: (i) preventing life-threatening arrhythmias during exercise; (ii) symptom management to allow sports; and (iii) preventing sports-induced progression of the arrhythmogenic condition. In each case, these three basic questions need to be addressed. Pre-excitation should be excluded in all athletes with PSVT, and ablation of the accessory pathway is recommended if present. In individuals with PVCs who want to engage in sports, underlying structural or familial arrhythmogenic conditions must be excluded, since sports activity may trigger more malignant arrhythmias if those underlying conditions are present. Athletes with electrical abnormalities of genetic origin, such as the inherited ion channelopathies, require assessment and shared decision making in which cardiogeneticists are involved, given the complex interplay of genotype, phenotype, potential modifiers, and exercise. Individuals with pacemakers should not be discouraged from participation in sport because of the device but need to tailor their sports participation according to the underlying disease. Participation in leisure-time and competitive sport in patients with an ICD may be considered, but requires shared and individualized decision making, based on a higher likelihood of appropriate and inappropriate shocks during sports, and the potential consequences of short episodes of loss of consciousness. Patients with CHD should be encouraged to exercise and should be given a personalized exercise prescription.

7 Gaps in evidence

Outcomes in exercising individuals with cardiovascular diseases. The natural history and absolute risk of conditions associated with SCD in athletes identified through CV screening is largely unknown, making it difficult to quantify short- and long-term risk. Prospective outcomes data, including the occurrence of major CV events and other CV morbidity, is needed to better guide risk stratification, management, and eligibility recommendations for athletes diagnosed with CVD.

Cardiovascular evaluation in master athletes. Current methods for screening individuals for atherosclerotic CAD are based on symptoms and a maximal exercise test; however, they do not identify individuals with mild to moderate atherosclerotic plaques. More knowledge on the optimal pre-participation screening algorithm for identifying individuals at risk of adverse cardiac events during exercise is required. Safety of high-intensity exercise in cardiovascular disease. There are limited data on the safety of high-intensity exercise training and sports participation in healthy individuals with a high burden of risk factors; more information can be gained through high-quality prospective studies in the future. Risk of anomalous origins of the coronary arteries in older individuals. Although AOCA from the opposite sinus of Valsalva are a recognized cause of mortality in young athletes, more knowledge is required on the risk of high-intensity exercise in older individuals (>40 years old), with this congenital abnormality. Risk of myocardial bridge. The precise significance of MB in causing MI or sudden death during exercise is unknown. Benefit of regular exercise on survival in chronic heart failure. Although exercise improves functional capacity and quality of life in individuals with HF, strong evidence on the benefit of regular exercise on survival is still lacking. Role of high-intensity exercise in chronic heart failure. The impact of high-intensity exercise in asymptomatic individuals with HF with reduced and preserved systolic function is unknown and large multicentre studies are required to facilitate exercise prescription in the future. Initiation of an exercise programme after decompensated heart failure. The start time of an exercise programme of moderate-high intensity and return to sports after an acute event in HF is unknown. Aquatic exercise in heart failure. The safety of aquatic exercise in HF needs to be confirmed by larger trials. Effect of exercise on the natural history of valvular heart disease. There is a paucity data on the effects of regular intensive exercise in individuals with valvular heart disease. Large-scale longitudinal studies are required to provide more evidence-based guidelines on exercise prescription in individuals with valvular heart disease. Effect of exercise on the natural history of aortopathies. There is a lack of knowledge on the impact of sport on progression of aortic disease and risk of dissection or aortic rupture among individuals with aortopathy. The impact of beta-blockers on progression of aortic disease among individuals with aortopathy who participate in regular exercise is unknown and should be investigated in a randomized controlled trial. Optimal safe exercise dose in cardiomyopathy. With an exception for arrhythmogenic cardiomyopathy, current practice relating to exercise recommendations in individuals with cardiomyopathy or following myopericarditis are largely based on circumstantial evidence. Large, adequately powered randomized prospective studies are necessary to provide evidence-based recommendations for optimal exercise prescription without compromising safety. Such Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026