Context

The 2025 American Heart Association/American College of Cardiology (AHA/ACC) scientific statement on Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities provides evolving insights and clinical guidance in the field of sports cardiology.¹ Prior to this statement, four key statements outlined the eligibility criteria for competitive athletes: Bethesda Conferences 16 (1985), 26 (1994), and 36 (2005), and the 2015 AHA/ACC scientific statement on Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities.² These recommendations form the foundation for decisions regarding risk assessment and participation in competitive sports. This expert analysis highlights notable updates from the perspective of clinicians who care for athletes.

Updates on the General Approach to Caring for Athletes

Focus on shared decision-making. The most important change is the clinician approach to assessing eligibility for sport, with a new section dedicated to shared decision-making (SDM) (Figure 1). The statement transitions away from paternalistic decision-making on whether a patient can or should participate in sport. Instead, participation should be based on collaborative discussion around disease-specific risks, sport-specific stressors, patient ambitions, and opportunities to mitigate risk. This is a change in tone for the statement, best expressed by the authors: "For the first time, we emphasize that this is not an article outlining 'disqualification recommendations,' but rather a compendium of clinical considerations that should guide the SDM process for athletes who present with cardiovascular abnormalities or disease."¹

Figure 1: Representation of the Practical Considerations of Shared Decision-Making

Reprinted with permission from Kim JH, Baggish AL, Levine BD, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025

Classification of sports. The revised statement characterizes the physiological stress from specific sporting activities as a continuum of endurance and strength, rather than the distinct categories seen in previous statements (Figure 2). This change acknowledges the nuanced physiological demands associated with a wide array of sports and, in turn, facilitates SDM discussions.

Figure 2: Representation of the Transition in the Definition of Sporting Activities Based on the Intensity of Endurance and Strength

Adapted with permission from (left panel) Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 1: classification of sports: dynamic, static, and impact: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2350-2355. doi:10.1016/j.jacc.2015.09.033; (right panel)
Kim JH, Baggish AL, Levine BD, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025

Incorporation of current evidence. Disease-specific clinical guidance has been updated to reflect newly available data since the last publication. For example, studies of athletes with hypertrophic cardiomyopathy (HCM), long QT syndrome, and implantable cardioverter-defibrillators (ICDs) have suggested that risks with sport are lower than previously thought.^1,3-5 Regarding etiology, in patients <35 years of age, unexplained, autopsy-negative (i.e., structurally normal hearts) sudden cardiac death (SCD) is likely the most common cause of death. In masters athletes (>35 years of age), ischemic heart disease is the most common etiology.

Pragmatic approach. The statement addresses common clinical dilemmas faced by clinicians. For example, it provides guidance on anticoagulation management by sport. Additionally, recommendations are in table format for quick reference, and the writing is easy to understand, making it useful for all members of an athlete's care team.

Disease-Specific Highlights

There are several refinements in approach to reflect evolving evidence and to facilitate SDM. A few of the conditions are highlighted in this expert analysis. Table 1 summarizes changes by disease compared with the 2015 statement recommendations.

Table 1: Variations in Sporting Participation as Outlined in the 2025 and 2015 ACC/AHA Guidelines

^a With expert counsel using an SDM approach and close disease surveillance
^b Except class IA sports
^c Class IA, IB, IC, and IIA
-ve = negative; +ve = positive; AC = anticoagulation; ACC = American College of Cardiology; ACM = arrhythmogenic cardiomyopathy; AHA = American Heart Association; AR = aortic regurgitation; AS = aortic stenosis; BAV = bicuspid aortic valve; BrS = Brugada syndrome; CPVT = catecholaminergic polymorphic ventricular tachycardia; cMRI = cardiac magnetic resonance imaging; DCM = dilated cardiomyopathy; ECG = electrocardiogram; HCM = hypertrophic cardiomyopathy; ICD = implantable cardioverter-defibrillator; LQTS = long QT syndrome; LV = left ventricular; MFS = Marfan syndrome; MR = mitral regurgitation; MS = mitral stenosis; PKP2 = plakophilin 2; SDM = shared decision-making; VF = ventricular fibrillation.

Masters athletes. The largest disease-specific change is the addition of a section on masters athletes addressing the difference in etiology of SCD/sudden cardiac arrest (SCA) among younger and older patients largely related to coronary artery disease (CAD). The statement includes useful algorithms for screening strategies, management of stable chronic CAD, and return to sport after acute events. Interestingly, the statement highlights the lower risk of cardiovascular events for athletes compared with their sedentary peers with coronary artery calcium and its limited utility in athletes at low risk.

ICD and arrhythmia. The statement incorporates guidance from the 2024 Heart Rhythm Society (HRS) Expert Consensus Statement on Arrhythmias in the Athlete.⁶ Notably, competition with ICDs is now considered to be reasonable, whereas the prior guidance was to restrict individuals. Athletes are also permitted to engage in collision sports, acknowledging the inherent risks of the potential damage to or malfunction of ICDs. Relatedly, resumption of sport after SCA is reasonable after clinical evaluation of recurrent risk and SDM.

Myopericarditis. Myocarditis and pericarditis are now separated to address differences in risk and management. Earlier resumption of activity (versus fixed time away from sport) is now reasonable after resolution of the acute phase of illness. For myocarditis, cardiac magnetic resonance imaging is favored for evaluation and arrhythmic risk stratification. Additionally, guidance related to coronavirus disease (COVID) 2019, long COVID, and vaccine-associated myocarditis is discussed.

Cardiomyopathies. The diagnosis of cardiomyopathy should no longer uniformly exclude athletes from competition, but rather expert assessments, genetic testing, and SDM should guide the approach. Specifically, recent data from athletes with HCM have suggested that the risk of participating in sport is relatively low and not uniform, leading to a change in recommendations.^7,8 Additionally, the statement acknowledges the low risk and nonspecific nature of isolated left ventricular (LV) hypertrabeculation in athletes and transitions away from a diagnosis of LV noncompaction cardiomyopathy as a unique disease.

Congenital heart disease. The paucity of data in this group has led to an individualized approach to participation, with an emphasis on physiology and longitudinal surveillance. In contrast to the 2015 statement recommendation, blanket restrictions to class IA activities are removed in favor of nuanced risk stratification with a focus on cardiopulmonary exercise testing. Markers of high risk in this group include significant ventricular dysfunction, hemodynamically significant or cyanotic lesions, uncontrolled arrhythmia, and severe pulmonary hypertension.

Thoracic aortic disease. The new statement addresses the uncertainty in pathological aortic enlargement, noting that aortic diameter >42 mm is abnormal in men and >40 mm is abnormal in women. As with the previous statement, risk stratification is based on the etiology of aortopathy: 1) BAV associated; 2) heritable thoracic aortic disease; and 3) unexplained enlargement. More specific guidance on surveillance and intervention is also discussed as it relates to sport.

Valvular disease. Many aspects remain consistent with the previous statement, emphasizing adherence to the established ACC/AHA guidelines.⁹ For severe valve disease, the approach has shifted from disqualification to weighing the risks and benefits of continued participation versus corrective intervention. There is also increased consideration for continued participation in individuals with arrhythmic mitral valve prolapse.

Supplementary conditions. The revised statement addresses the management of pulmonary embolism, participation in extreme exercise environments, and considerations during pregnancy.

Conclusion

In summary, the revised statement has shifted from a one-size-fits-all approach to personalized risk assessment that considers the athlete's unique disease status, the demands of their sport, and their individual propensity for risk. Absolute restriction from sport has been replaced with individualized risk/benefit evaluations, SDM, and close longitudinal surveillance to guide participation in sport.

References

1. Kim JH, Baggish AL, Levine BD, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025
2. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2343-2349. doi:10.1016/j.jacc.2015.09.032
3. Martinez KA, Bos JM, Baggish AL, et al. Return-to-play for elite athletes with genetic heart diseases predisposing to sudden cardiac death. J Am Coll Cardiol. 2023;82(8):661-670. doi:10.1016/j.jacc.2023.05.059
4. Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation. 2013;127(20):2021-2030. doi:10.1161/CIRCULATIONAHA.112.000447
5. Saarel EV, Law I, Berul CI, et al. Safety of sports for young patients with implantable cardioverter-defibrillators: long-term results of the multinational ICD sports registry. Circ Arrhythm Electrophysiol. 2018;11(11):e006305. doi:10.1161/CIRCEP.118.006305
6. Lampert R, Chung EH, Ackerman MJ, et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play. Heart Rhythm. 2024;21(10):e151-e252. doi:10.1016/j.hrthm.2024.05.018
7. Lampert R, Ackerman MJ, Marino BS, et al. Vigorous exercise in patients with hypertrophic cardiomyopathy. JAMA Cardiol. 2023;8(6):595-605. doi:10.1001/jamacardio.2023.1042
8. Sivalokanathan S, Lampert RJ. CV Sports Chat: Moving From Exercise Prescription to Shared Decision Making (ACC website). 2023. Available at: https://www.acc.org/Latest-in-Cardiology/Articles/2023/10/05/11/49/CV-Sports-Chat. Accessed 11/07/2025.
9. Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;77(4):e25-e197. doi:10.1016/j.jacc.2020.11.018