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Recommendations for participation in sports in heart failure Before considering a sport activity, a preliminary optimization of HF risk factor control and therapy, including device implantation (if appropriate), is recommended. I C High-intensity power and endurance sports are not recommended in patients with HFrEF irrespective of symptoms. III C Recommendations for exercise and participation in sports in individuals with heart failure and preserved ejection fraction Moderate endurance and dynamic resistance exercise, together with lifestyle intervention and optimal treatment of CV risk factors (i.e. arterial hypertension and type 2 diabetes) are recommended. I C Recommendations for exercise and participation in sports in individuals with heart transplant recipients Regular exercise through cardiac rehabilitation combining moderate-intensity aerobic and resistance exercise is recommended to revert pathophysiology to pre-transplantation time, reduce CV risk induced by post-transplantation medical treatment, and improve clinical outcome. I B Recommendations for exercise in asymptomatic individuals with valvular heart disease Participation in competitive or recreational sports/exercise of moderate and high intensity is not recommended in individuals with severe aortic stenosis. III C Participation in competitive or recreational sports/exercise of moderate and high intensity is not recommended in individuals with severe aortic regurgitation with LVEF<_50% and/or exercise-induced arrhythmias. III C Participation in competitive sports is not recommended in individuals with severe mitral regurgitation with a LVEF<60%. III C Participation in any competitive sport, or leisure sports/exercise of mild to moderate intensity, is not recommended in individuals with severe (MVA<1 cm2) mitral stenosis. III C Recommendations for exercise in individuals with aortic pathology Prior to engaging in exercise, risk stratification, with careful assessment including advanced imaging of the aorta (CT/CMR) and exercise testing with BP assessment, is recommended. I A Competitive sports are not recommended in individuals who are at high risk (Table 14). III C Recommendations for exercise in individuals with cardiomyopathy General recommendation Annual assessment for risk stratification is recommended in all individuals with cardiomyopathy who exercise regularly. I C Recommendations for exercise and sports participation in individuals with hypertrophic cardiomyopathy Participation in high-intensity exercise (including recreational and competitive sports) is not recommended in individuals who have ANY markers of increased risk [(i) cardiac symptoms or history of cardiac arrest or unexplained syncope; (ii) moderate ESC risk score (>_4%) at 5 years; (iii) LVOT gradient at rest >30 mmHg; (iv) abnormal BP response to exercise; (v) exercise-induced arrhythmias]. III C Recommendations for exercise and sports participation in individuals with arrhythmogenic cardiomyopathy Participation in high-intensity recreational exercise/sports or any competitive sports is not recommended in individuals with ACM including those who are genotype positive and phenotype negative. III C Recommendations for exercise and sports participation in individuals with left ventricular non-compaction cardiomyopathy Participation in high-intensity exercise or competitive sports is not recommended in individuals with symptoms, LVEF<40% and/or frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing. III C Recommendations for exercise and sports participation in individuals with dilated cardiomyopathy Participation in high- or very high-intensity exercise including competitive sports is not recommended for individuals with a DCM and any of the following: (i) symptoms or history of cardiac arrest or unexplained syncope; (ii) LVEF<45%; (iii) frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing; (iv) extensive LGE (>20%) on CMR; or (v) high-risk genotype (lamin A/C or filamin C). III C Recommendations for exercise in individuals with myocarditis and pericarditis Comprehensive evaluation, using imaging studies, exercise stress test, and Holter monitoring, is recommended following recovery from acute myocarditis to assess the risk of exercise-related SCD. I B Return to all forms of exercise including competitive sports is recommended after 30 days to 3 months of rest for individuals who have recovered completely from acute pericarditis, depending on clinical severity. I C Among individuals with a probable or definitive diagnosis of recent myocarditis or pericarditis, participation in leisure-time or competitive sports while active inflammation is present is not recommended. III C Participation in moderate- to high-intensity exercise for a period of 36 months after acute myocarditis is not recommended. III B Participation in moderate- to high-intensity exercise, including competitive sports, is not recommended for individuals with constrictive pericarditis. III C

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