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............................................................................................................................................................................. consultations for other considerations, physicians are encouraged to promote exercise in all patients.

Although proportionately scarce, exercise may paradoxically trigger sudden cardiac arrest (SCA) in individuals with CVD, particularly those who were previously sedentary or have advanced CVD.4,5 In parallel with the drive to promote exercise in all individuals,6 it is anticipated that physicians will be confronted with an increasing number of enquiries from individuals with established risk factors for coronary artery disease (CAD) or established CVDs about participation in exercise programmes and recreational sports activities. Such consultations need to strike a balance between the multiple benefits of exercise, the small risk of sudden death, and the patient’s goals for cardiorespiratory fitness and ongoing participation in relatively strenuous exercise following a CV diagnosis. The current Guidelines for exercise and sports participation in individuals with CVD are the first of a kind by the ESC. Sports cardiology is a relatively novel and emerging sub-speciality, therefore the evidence base for the natural history of disease progression or risk of death during intensive exercise and competitive sport among individuals with CVD is relatively sparse. This is reflected by the fact that a disproportionately large number of recommendations are reliant on the wisdom and vast experience of the consensus group rather than on large prospective studies. We acknowledge the inherent difficulties in formulating recommendations for all scenarios in a heterogeneous population with a diverse spectrum of CVDs in light of the limited availability of evidence. Therefore, these recommendations should not be considered as legally binding and should not discourage individual physicians from practising outside the remit of this document, based on their clinical experience in sports cardiology. Where possible, the Guidelines have included the most up-to-date research in exercising individuals with CVD. The current Guidelines also draw upon existing ESC Guidelines for the investigation, risk assessment, and management of individuals with CVDs to aid physicians when prescribing exercise programmes or providing advice for sports participation. We hope that the document will serve as a useful clinical guide but also as an incentive for future research to challenge established wisdom. In line with good clinical practice, the present document encourages shared decision making with the athlete patient and respects the autonomy of the individual after provision of detailed information about the impact of sports and the potential risks of complications and/or adverse events (Central illustration). Similarly, all exercise prescription and related discussions between the individual and the physician should be documented in the medical report.

3 Identification of cardiovascular

disease and risk stratification in individuals participating in recreational and competitive sports

3.1 Introduction

Higher levels of PA and fitness are associated with lower all-cause mortality, lower rates of CVD, and lower prevalence of several known malignancies.716 Despite the substantial health benefits provided by regular PA, intense exercise may paradoxically act as a trigger for life-threatening ventricular arrhythmias (VAs) in the presence of underlying CVD. Indeed, sudden cardiac death (SCD) is the leading cause of sports and exercise-related mortality in athletes.1719 CV safety during sports participation for individuals at all levels and ages is imperative to avoid catastrophic and often preventable SCD and has become a common goal among medical and sports governing organizations.2024

Pre-participation CV screening aimed at the detection of disorders associated with SCD is universally supported by major medical societies.2022,25,26 However, the best method for CV screening of young competitive athletes (<35 years old) remains controversial, and limited data are available to guide recommendations in master athletes (>_35 years old) Screening strategies must be tailored to the target population and the specific disorders with highest risk. SCD in young athletes is caused by a variety of structural and electrical disorders of the heart, including cardiomyopathies, ion channel disorders, coronary anomalies, and acquired cardiac conditions.17,27,28 In adult and senior athletes, atherosclerotic CAD is the primary condition leading to major adverse cardiovascular events (MACE).28,29

3.2 Definitions of recreational and

competitive athletes The ESC defines an athlete as ‘an individual of young or adult age, either amateur or professional, who is engaged in regular exercise training and participates in official sports competition’.1,30 Similarly, the American Heart Association (AHA) and others define a competitive athlete as an individual involved in regular (usually intense) training in organized individual or team sports, with an emphasis on competition and performance.31,32 Athletes involved in competitive sports span the age spectrum and can compete at the youth, high school, academy, university, semi-professional, professional, national, international, and Olympic levels. As a distinction, a recreational athlete engages in sports for pleasure and leisure-time activity, whereas a competitive athlete is highly trained with a greater emphasis on performance and winning. In a proposed classification of athletes based on the minimum volume of exercise, ‘elite’ athletes (i.e. national team, Olympians, and professional athletes) generally exercise >_10 h/week; ‘competitive’ athletes [i.e. high school, college, and older (master) club level athletes] exercise >_6 h/week; and ‘recreational’ athletes exercise >_4 h/week.33 This distinction is somewhat arbitrary since some recreational athletes, such as long-distance cyclists and runners, engage in exercise at higher volumes than some professional athletes participating in skill sports.

3.3 Exercise-related major adverse cardi-

ovascular events Exercise-related MACE include SCA and SCD; acute coronary syndromes (ACS) such as myocardial ischaemia and myocardial infarction (MI); transient ischaemic attacks (TIA) and cerebrovascular accidents (CVA); and supraventricular tachyarrhythmias. SCA is defined as an unexpected collapse due to a cardiac cause in which cardiopulmonary resuscitation (CPR) and/or defibrillation is provided in an individual regardless of the survival outcome.17,27,32 Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026