The following are key points to remember from these updated recommendations of the Sports Cardiology Section of the European Association of Preventive Cardiology on sports-participation in athletes-patients with coronary artery disease (CAD):

1. Exercise stress testing remains the pivotal test to evaluate the patient-athlete who wishes to enter competitive sports.
2. In general, if the maximal exercise test is normal and the cardiovascular risk factor profile is low, the presence of relevant CAD is assumed to be unlikely. In this instance, no additional tests are mandatory and no restriction for competitive sports is advised. Risk factor management should be adequate and annual follow-up is recommended.
3. In case of a borderline or equivocal exercise test result (e.g., ST depression of 0, 15 mV, not typically ascending ST segment, etc.), as well as in the case of an uninterpretable electrocardiogram (pre-existing left bundle branch block or ventricular pacing), an additional stress test such as stress-echocardiography/cardiac magnetic resonance imaging/positron emission tomography/single-photon emission computed tomography (SPECT) should be performed. The panel advises maximal exercise SPECT as a first diagnostic step in athletes. However, the option of exercise echocardiography or nuclear perfusion techniques (exercise or pharmacological) is also available. The choice of these tests is guided by their diagnostic accuracy, being dependent on local expertise, and by their availability.
4. If the exercise test is positive, preferentially a CT or coronary angiogram should be performed to confirm the presence and extent of CAD. In case a CT shows the presence of significant lesions, according to routine clinical criteria, the patient-athlete should undergo coronary angiography. It should be noticed that master endurance athletes show a higher degree, and a more diffuse distribution of coronary calcium in the coronary tree compared with nonathletes at a similar low risk-factor level.
5. The athlete-patient should periodically be reassessed regarding risk profile and progression/regression of CAD.
6. Athletes-patients with clinically proven CAD, considered as having a low probability for events (anatomically as well as functionally), are eligible for most sports, also at a competitive level, based on individual evaluation.
7. However, exceptions apply for high-intensity sports (intensive power and endurance sport) and athletes-patients of older age (>60 years).
8. Patients-athletes with clinically proven CAD, defined as high risk, should be temporarily restricted from competitive sports and receive appropriate management.
9. For individuals with coronary artery anomalies such as coronary originating from the wrong sinus, with acute angled take-off from the aorta and anomalous coursing between the aorta and the pulmonary artery, participation in high-intensity sports is discouraged prior to successful correction.
10. Asymptomatic athletes-patients with myocardial bridging can participate in all competitive and leisure-time sports. Conversely, those with evidence of ischemia or symptoms should be restricted from participation in competitive sports, and should be properly advised regarding leisure-time activities.

Keywords: Athletes, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Echocardiography, Echocardiography, Stress, Exercise Test, Leisure Activities, Magnetic Resonance Imaging, Myocardial Bridging, Myocardial Ischemia, Plaque, Atherosclerotic, Positron-Emission Tomography, Primary Prevention, Risk Factors, Sports, Tomography, Emission-Computed, Single-Photon, Tomography, X-Ray Computed

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