The following are key points to remember from a guideline comparison on participation in competitive sports by patients with congenital heart disease:

1. This manuscript compares the format and methodology of the 2015 American Heart Association/American College of Cardiology (AHA/ACC) with the 2020 European Association of Preventive Cardiology/European Society of Cardiology/Association for European Paediatric and Congenital Cardiology (EAPC/ESC/AEPC) guidelines for sports participation in patients with congenital heart disease.
2. Both sets of guidelines are based on predominately Level of Evidence C (Expert Consensus).
3. The AHA/ACC guidelines begin with the anatomic defect and repaired/unrepaired status, followed by associated symptoms and hemodynamic status.
4. The European guidelines categorize sports based on expected hemodynamic changes into four categories: Power, Skill, Mixed, and Endurance.
5. The European statement introduces a 5-step algorithm consisting of the following: 1) obtaining a history and performing a physical exam, 2) performing a hemodynamic and electrophysiological assessment at rest, 3) performing a hemodynamic and electrophysiological assessment during exercise, 4) making recommendations based on the totality of gathered information, 5) and following up the patient after recommendations are implemented.
6. Resting parameters recommended by the European statement include assessment of ventricular structure and function (echo and/or magnetic resonance imaging), pulmonary artery pressure, presence of arrhythmia (home monitoring), aortic diameters, and oxygen saturation.
7. Exercise parameters are ideally measured with a cardiopulmonary exercise test and include arterial oxygen saturation, arrhythmia, peak oxygen consumption, heart rate reserve, ventilatory efficiency slope, O₂ pulse, gas exchange threshold, ischemia, and blood pressure response to exercise.
8. Both sets of guidelines are intended for athletes considering participation in competitive as opposed to recreational sports and activities.
9. The ACC/AHA guidelines can lead to a disconnect between recommendations for sports participation and recommendations for intervention. For example, a patient could be restricted from sports based on hemodynamic status, but not meet criteria for intervention.
10. Ideally, future work will lead to an aligned guideline endorsed by both the ACC/AHA and EAPC/ESC/AEPC process. In the meantime, cardiologists should prioritize individualized assessments tailored to each patient’s unique condition and include shared decision-making with patients and their families.

Clinical Topics: Congenital Heart Disease and Pediatric Cardiology, Sports and Exercise Cardiology, Congenital Heart Disease, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology

Keywords: Heart Defects, Congenital, Sports

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