The following are key points to remember from the European Association of Preventive Cardiology Position Statement on recommendations for participation in competitive and leisure sport in athletes with cardiomyopathies, myocarditis, and pericarditis:

1. Background. This document is an update to the 2005 European Society of Cardiology (ESC) recommendations for sport participation in athletes with cardiovascular diseases. It is intended as a practical guide to sports cardiologists, physicians, and cardiovascular team members caring for athletes with cardiomyopathies and myopericarditis. The updates in diagnosis and recommendations for risk stratification and management are based on emerging data and expert opinion.
2. Shared decision making. New in this document is an emphasis on an individualized approach to management that accounts for symptoms, risk factors for sudden cardiac death (SCD), natural history of disease, age, intensity of exercise, and type of sport. The personal and professional consequences at stake require respect of patient autonomy. The roles of various stakeholders such as trainers, coaches, sporting organizations, and country-specific norms and legal systems will influence the shared decision-making process.
3. Diagnosis of cardiomyopathy in athletes. Workup of an athlete with possible cardiomyopathy includes detailed history and physical, electrocardiogram (ECG), echocardiogram, and cardiac magnetic resonance imaging (MRI). Differentiation between physiologic and pathologic adaptations—electrical and structural—can be particularly challenging in endurance athletes and black athletes.
4. Hypertrophic cardiomyopathy (HCM). Recommendations: Exercise participation should be considered on an individual basis. Findings that might represent absolute contraindications for sports participation include history of aborted SCD, unexplained syncope, exercise-induced ventricular tachycardia (VT), high ESC 5-year risk score, significant increase in left ventricular (LV) outflow gradient (>50 mm Hg), and abnormal blood pressure response to exercise. Following a comprehensive evaluation and shared decision discussion between patient and care team, adult athletes with mild clinical expressions of HCM and low ESC risk score, may selectively be allowed to participate in competitive sports, with the exception of those sports with intrinsic risk of harm with syncope (e.g., scuba diving). Genotype positive–phenotype negative status should not equate to having HCM and thus should not preclude participation in sports.
5. Dilated cardiomyopathy (DCM). Recommendations: LV cavity dilatation with preserved LV function in isolation (no family history of DCM, abnormal ECG patterns, or atrial/ventricular tachyarrhythmias) should be considered physiologic cardiac remodeling rather than DCM. Athletes with an unequivocal diagnosis of DCM but only mildly reduced LV systolic function (ejection fraction [EF] ≥40%) may selectively engage in sports if they are asymptomatic, without prior history of unexplained syncope, and without frequent/complex ventricular tachyarrhythmias on ambulatory ECG monitoring and exercise stress testing. However, patients with a family history of SCD and/or those with mutations that are associated with an increased risk of life-threatening arrhythmias (e.g., Lamin A/C or Filamin C mutation) should be advised not to engage in competitive sports. Athletes with a diagnosis of DCM who are symptomatic, or have LVEF <40%, or extensive late gadolinium enhancement (LGE) (i.e., >20%) on cardiac MRI, and/or frequent ventricular tachyarrhythmias on ambulatory ECG monitoring and exercise stress testing, or unexplained syncope, should be advised to limit their exercise to leisure-time activities and undergo regular clinical surveillance. Genotype positive–phenotype negative individuals may participate in all sports but should receive at least annual evaluations.
6. LV noncompaction cardiomyopathy (LVNC). Recommendations: Athletes with incidental discovery of LV hypertrabeculation should not be diagnosed as LVNC as long as there are no symptoms, positive family history, abnormal ECG patterns and, most importantly, impaired LV function. Athletes with the diagnosis of LVNC but near-normal LV systolic function may selectively participate in competitive sports if asymptomatic, without frequent ventricular arrhythmias or nonsustained VT on ambulatory monitoring and exercise stress testing, and no prior history of unexplained syncope. Athletes with the diagnosis of LVNC and impaired LV systolic function and/or frequent ventricular arrhythmias or nonsustained VT on ambulatory monitoring or exercise testing should be advised to limit their exercise to leisure-time physical activities and have regular clinical surveillance.
7. Arrhythmogenic (right ventricular) cardiomyopathy (ARVC/AC). Recommendations: Athletes with the diagnosis of AC should not participate in competitive sports and limit exercise to leisure-time activities and have regular follow-up. Of note, life-long endurance athletes with exercise-induced RV cardiomyopathy, clinically indistinguishable from AC, should have the same workup and recommendations. Athletes who are genetic carriers of pathogenic AC-associated desmosomal mutations (even if phenotype negative) should limit their exercise to leisure-time activities and be followed regularly.
8. Athletes with isolated ECG abnormalities. Recommendations: Athletes with a markedly abnormal ECG but no features of cardiomyopathy should not be considered as affected by cardiomyopathy. However, given the potential for developing a cardiomyopathy, especially if T-wave inversion in inferior and lateral leads are seen, these individuals should be evaluated annually during adolescence and young adulthood and educated on potential cardiac symptoms.
9. Athletes with cardiomyopathy and implanted cardioverter-defibrillator (ICD). Recommendations: The desire of the athlete with cardiomyopathy to compete should not constitute a primary (or unique) indication for ICD implantation. Although it will prevent SCD, recommendation for sports participation in an individual with an ICD should acknowledge that the ICD does not prevent malignant arrhythmia, especially during intensive exercise. Participation in competitive sports may be considered after careful consideration of the type of underlying cardiomyopathy, the risks of sports participation with an ICD, including the likelihood of appropriate/inappropriate shocks, lead failure, and device-related trauma.
10. Prescription for leisure-time physical activity in patients with cardiomyopathy. Recommendations: Leisure-time (i.e., recreational, noncompetitive) exercise is probably not as detrimental as previously thought. Recent studies support a less restrictive approach to low- to moderate-intensity exercise in patients with HCM and ARVC.
11. Myocarditis. Recommendations: Athletes diagnosed with myocarditis should be restricted from exercise for 3–6 months to promote resolution of inflammation, depending on the clinical severity and duration of the illness, LV function, and extent of inflammation on cardiac MRI. Athletes with a history of myocarditis have increased risk of recurrence and therefore should undergo periodical reassessment, especially within the first 2 years. It is reasonable for athletes to resume training and competition if all of the following criteria are met: LV systolic function has returned to the normal range, serum biomarkers of myocardial injury have normalized, and clinically relevant arrhythmias are absent on ECG monitoring and exercise stress testing. The clinical significance of persistent LGE in an asymptomatic athlete with prior myocarditis is unknown. Myocardial scar is a potential source of ventricular tachyarrhythmias. At present, it seems reasonable to allow participation in competitive sports if LV function is preserved and if no ventricular or supraventricular arrhythmias are seen on ECG monitoring or exercise stress testing. Asymptomatic athletes with LGE, however, should continue to be followed annually.
12. Pericarditis. Recommendations: Athletes with pericarditis should be restricted from competitive sports during the acute phase. Three months is considered an appropriate time frame to allow for resolution of inflammation, but shorter periods (e.g., 1 month) may be considered if the clinical picture is mild and resolution is prompt. It is reasonable to return to play if the serum biomarkers have normalized, LV function is normal, ECG changes have normalized, and there are no resting or exercise-induced ventricular arrhythmias detectable on ECG monitoring or exercise stress testing. Asymptomatic athletes with a small pericardial effusion and without biochemical and cardiac MRI evidence of myocardial inflammation should not be diagnosed with myopericarditis and should not be restricted from sports.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, Sports and Exercise Cardiology, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Atrial Fibrillation, Blood Pressure, Cardiomyopathies, Cardiomyopathy, Dilated, Cardiomyopathy, Hypertrophic, Death, Sudden, Cardiac, Defibrillators, Implantable, Dilatation, Electrocardiography, Echocardiography, Exercise, Exercise Test, Gadolinium, Genotype, Heart Failure, Inflammation, Magnetic Resonance Imaging, Monitoring, Ambulatory, Mutation, Myocarditis, Pericardial Effusion, Pericarditis, Phenotype, Primary Prevention, Risk Factors, Sports, Stroke Volume, Syncope, Tachycardia, Tachycardia, Ventricular

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