The following are key points to remember from the 2020 European Society of Cardiology (ESC) guidelines on sports cardiology and exercise in patients with cardiovascular disease (CVD):

1. General: This is a comprehensive, well-organized document, covering a broad spectrum of cardiovascular (CV) conditions. Shared decision making is emphasized and gaps in evidence are acknowledged. Sex differences are also recognized, including the lower incidence of sudden cardiac death (SCD) in females and differences in physiologic and pathologic adaptation to exercise in female athletes.

   This document covers exercise recommendations in athletes with:

2. Cardiovascular Risk Factors: SCD is the leading cause of exercise-associated mortality in athletes; in athletes >35 years old, the majority of SCDs are attributed to coronary artery disease (CAD); preparticipation CV screening in recreational and competitive athletes is aimed at the detection of disorders associated with SCD; healthy adults of all ages and individuals with known CVD should exercise on most days for 150 minutes/week or more at a moderate-intensity level; establishing the maximal exercise capacity via a maximal exercise stress test (preferably cardiopulmonary exercise test [CPET]) facilitates exercise recommendations.
3. Chronic and Acute Coronary Syndrome: CV screening in adult athletes should include an assessment of CV risk factors and an exercise stress test; coronary artery calcium (CAC) scoring may be considered in asymptomatic athletes with a moderate atherosclerotic risk profile; individuals with low risk for exercise-induced adverse events are 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 ischemia; after an acute coronary syndrome event, cardiac rehabilitation and follow-up echocardiogram and exercise testing (CPET) are recommended; ischemia should be ruled out when evaluating an athlete with anomalous origin of the coronaries.
4. Chronic Heart Failure: Exercise programs improve exercise tolerance and quality of life but should be initiated only after medical therapy is optimized; a maximal exercise stress test (CPET) is important for baseline assessment of functional capacity, hemodynamic response, and arrhythmia inducibility with exercise; cardiac rehabilitation is a cornerstone of management of heart failure with preserved ejection fraction.
5. Valvular Heart Disease: Asymptomatic individuals with mild valvular heart disease may participate in competitive sports; asymptomatic individuals with moderate valve disease, good functional capacity, and no evidence of myocardial ischemia, complex arrhythmias, or hemodynamic compromise on a maximal exercise stress test may participate in competitive sports following a shared decision discussion; mitral valve prolapse is a relatively benign condition unless high risk features are present.
6. Aortopathy: Those with aortic root <40 mm are at lowest risk; risk stratification via exercise testing and imaging (computed tomography/cardiac magnetic resonance imaging) is recommended prior to exercise initiation; sports participation decreases the risk of CV events and mortality in athletes with aortopathies.
7. Cardiomyopathies, myocarditis, and pericarditis: In patients with hypertrophic cardiomyopathy, an individualized approach should be taken toward sports participation; individuals with acute myocarditis or pericarditis should avoid participation in sports while active inflammation is present; athletes with resolved myocarditis or pericarditis should undergo comprehensive CV evaluation, including an exercise test, to assess the risk of exercise-induced arrhythmias, usually 3-6 months after the diagnosis is made (sooner for pericarditis); a mildly reduced left ventricular ejection fraction (LVEF) with cavity enlargement could reflect physiologic adaptation or a dilated cardiomyopathy, necessitating assessment of LV function during exercise; high-intensity exercise has been shown to influence progression of arrhythmogenic cardiomyopathy and thus is not recommended.
8. Arrhythmias and channelopathies: Management is guided by three principles: (i) preventing life-threatening arrhythmias during exercise; (ii) symptom management; and (iii) preventing sports-induced progression of the arrhythmogenic condition; in athletes with supraventricular tachycardia (SVT), pre-excitation should be excluded, and curative treatment via catheter ablation should be considered; intermittent pre-excitation might be indicative of a low risk (i.e., for pre-excited atrial fibrillation (AF) accessory pathway, but adrenergic stimulation can enhance pre-excitation; if pre-excitation is manifest, ablation is recommended if SVT has been documented; in competitive, professional level athletes with asymptomatic pre-excitation, an electrophysiology study is recommended to rule out high-risk features; moderate-level exercise is recommended to prevent AF; for those with recurrent symptomatic AF, catheter ablation is recommended, especially in those not wanting to take or intolerant of medical therapy; atrial flutter ablation should be considered in those with documented flutter and could facilitate use of Class I antiarrhythmics for AF; athletes with premature ventricular contractions need to be evaluated for underlying structural or familial arrhythmogenic conditions; for athletes with inherited ion channelopathies, such as long QT syndrome and Brugada syndrome, shared decision making is indicated with cardiogeneticists and electrophysiologists as appropriate; patients with pacemakers should be encouraged to exercise but need to mindful of the underlying condition(s); exercise recommendations in the implantable cardioverter-defibrillator patient require shared decision making due to the potential for shocks during sports and potential consequences of syncope.
9. Congenital heart disease: Patients with congenital heart disease should be encouraged to exercise following physiological assessment of their condition; five baseline parameters to be evaluated are ventricular function, pulmonary artery pressure, aortic size, arrhythmia, and oxygen saturation; CPET is instrumental in the evaluation of this patient population.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Valvular Heart Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Exercise, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise and ECG and Stress Testing

Keywords: ESC Congress, ESC20, Acute Coronary Syndrome, Arrhythmias, Cardiac, Atrial Fibrillation, Athletes, Cardiac Rehabilitation, Cardiomyopathies, Catheter Ablation, Death, Sudden, Cardiac, Exercise, Exercise Test, Heart Defects, Congenital, Heart Failure, Heart Valve Diseases, Myocarditis, Pericarditis, Primary Prevention, Risk Factors, Sports

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