The Sports and Exercise Cardiology sessions at American College of Cardiology Annual Scientific Session 2026 (ACC.26) reinforced a central theme: exercise is both medicine and, in select contexts, a risk. Across sessions including "Cleared For Competition? Consideration of Risks of Competitive Sports For Athletes With Heart Disease" and "When is Exercise the Risk? And When is It the Rx?," the field continued to move away from binary eligibility decisions toward individualized, longitudinal risk assessment. Speakers highlighted the complexity of evaluating athletes with structural, genetic, and congenital cardiovascular (CV) conditions, emphasizing that eligibility decisions are rarely static.

For athletes with aortic dilation, careful phenotyping is essential, with evaluation of underlying etiology including consideration of genetic syndromes. Rather than imposing uniform restrictions, clinicians were encouraged to individualize recommendations. This individualization stems from the growing necessity of and ethnical imperative for shared decision-making (SDM), a framework that represents a fundamental departure from the more paternalistic disqualification years of sports cardiology.^1,2

Panelists emphasized that SDM is not a single conversation but a longitudinal process that balances clinical data with the athlete's personal values and risk tolerance. This process is particularly critical in the management of genetic cardiomyopathies, for which athletes may face accelerated disease progression and heightened arrhythmic risk with intensive training. In these instances, clarifying how important continued sports participation is to the athlete, and at what intensity, can help guide the clinical path.

The framework discussed involves a multidisciplinary approach, incorporating electrophysiologists, genetic counselors, imaging specialists, and the athlete's support system, among others. A key takeaway from the sessions was the necessity of transparency regarding the gray zones of evidence.³ Clinicians were encouraged to explicitly quantify risk when possible while acknowledging the limitations of current natural history data for athletes who continue to train and compete. Furthermore, SDM requires a deep dive into the psychological and socioeconomic impact of sports cessation. By documenting the athlete's goals and their understanding of potential events, the clinician moves from a role of gatekeeper to more of a risk navigator. This collaborative model ensures that the final athletic plan, which may include modified training volumes or personal automated external defibrillators, is both medically informed and personally sustainable.

Beyond these disease-specific considerations, sessions also addressed the broader landscape of CV risk in athletes. A major focus was the evolving understanding that fitness attenuates but does not eliminate CV risk. In masters athletes, coronary artery disease remains the leading cause of sudden cardiac death, and the presence of coronary artery calcium is common in male masters athletes. The concept of the exercise paradox was revisited, in which habitual exercise lowers long-term CV risk yet vigorous exertion transiently increases the likelihood of acute CV events in those with underlying disease. Thus, clinicians were encouraged to move beyond assumptions of protection and to instead focus on comprehensive risk-assessment and prevention strategies. Aggressive control of modifiable risk factors, including hyperlipidemia, hypertension, and diet, was emphasized as an essential component of minimizing CV risk in masters athletes.

Another key theme was the importance of clinical vigilance, particularly for subtle or atypical symptoms in athletes. Declines in performance, inability to maintain pace, or atypical exertional discomfort may represent early warning signs of underlying cardiovascular disease (CVD) in athletes who may downplay or disregard symptoms. Diagnostic testing should be appropriately rigorous, and reassurance should not rely solely on high exercise capacity.

Beyond didactic sessions, ACC.26 highlighted the growing role of cardiopulmonary exercise testing (CPET) through interactive, hands-on learning experiences. These live demonstrations reinforced CPET as a core skill in sports cardiology, bridging exercise physiology with real-world clinical decision-making and providing a practical framework for integrating exercise data into patient care. The sessions emphasized the importance of using normative values derived in cohorts of athletes because supranormal values are the baseline for endurance athletes. Peak oxygen consumption (VO₂) prediction equations derived in the general population may significantly underestimate the peak VO₂ of endurance athletes and result in more false-negative testing results and missed clinically relevant CVD.⁴

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. Martinez MW, Kim JH, Shah AB, et al. Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol. 2021;78(14):1453-1470. doi:10.1016/j.jacc.2021.08.003
3. Danielian A, Shah AB. Differentiating physiology from pathology: the gray zones of the athlete's heart. Clin Sports Med. 2022;41(3):425-440. doi:10.1016/j.csm.2022.02.005
4. Petek BJ, Tso JV, Churchill TW, et al. Normative cardiopulmonary exercise data for endurance athletes: the Cardiopulmonary Health and Endurance Exercise Registry (CHEER). Eur J Prev Cardiol. 2022;29(3):536-544. doi:10.1093/eurjpc/zwab150