European Heart Journal (2020) 00,1À80 ESC GUIDELINES doi:10.1093/eurheartj/ehaa605 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease The Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC) Authors/Task Force Members: Antonio Pelliccia* (Chairperson) (Italy), Sanjay Sharma* (Chairperson) (United Kingdom), Sabiha Gati (United Kingdom), Maria Back€ (Sweden), Mats Bo¨rjesson (Sweden), Stefano Caselli (Switzerland), Jean-Philippe Collet (France), Domenico Corrado (Italy), Jonathan A. Drezner (United States of America), Martin Halle (Germany), Dominique Hansen (Belgium), Hein Heidbuchel (Belgium), Jonathan Myers (United States of America), Josef Niebauer (Austria), Michael Papadakis (United Kingdom), Massimo Francesco Piepoli (Italy), Eva Prescott (Denmark), Jolien W. Roos-Hesselink (Netherlands), A. Graham Stuart (United Kingdom), Rod S. Taylor (United Kingdom), Paul D. Thompson (United States of America), Monica Tiberi (Italy), Luc Vanhees (Belgium), Matthias Wilhelm (Switzerland) Document Reviewers: Marco Guazzi (CPG Review Coordinator) (Italy), Andre´ La Gerche (CPG Review Coordinator) (Australia), Victor Aboyans (France), Paolo Emilio Adami (Italy), Johannes Backs (Germany), Aaron Baggish (United States of America), Cristina Basso (Italy), Alessandro Biffi (Italy), Chiara Bucciarelli-Ducci (United Kingdom), A. John Camm (United Kingdom), Guido Claessen (Belgium), Victoria Delgado (Netherlands), Perry M. Elliott (United Kingdom), Maurizio Galderisi† (Italy), Chris P. Gale (United Kingdom), Belinda Gray (Australia), Kristina Hermann Haugaa (Norway), Bernard Iung (France), Hugo A. Katus (Germany), Andre Keren (Israel), Christophe Leclercq (France), * Corresponding authors: Antonio Pelliccia, Department of Medicine, Institute of Sport Medicine and Science, Rome, Italy. Tel: þ39 06 3275 9230, Email: antonio.pelliccia@coni. it; [email protected]. Sanjay Sharma, Cardiology Clinical Academic Group, St George’s, University of London, London, United Kingdom. Tel: þ44 (0)20 8725 6878, Email: [email protected]. † We would like to pay tribute to Professor Galderisi who passed away in March 2020. ESC Committee for Practice Guidelines (CPG), National Cardiac Societies document reviewers and Author/Task Force Member affiliations: listed in the Appendix. ESC entities having participated in the development of this document: Associations: Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Working Groups: Adult Congenital Heart Disease. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC ([email protected]). Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom- mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour- aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. VC The European Society of Cardiology 2020. All rights reserved. For permissions, please email: [email protected]. 2 ESC Guidelines Basil S. Lewis (Israel), Lluis Mont (Spain), Christian Mueller (Switzerland), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Marco Roffi (Switzerland), Kai Savonen (Finland), Luis Serratosa (Spain), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Marta Sitges (Spain), Erik Ekker Solberg (Norway), Miguel Sousa-Uva (Portugal), Emeline Van Craenenbroeck (Belgium), Caroline Van De Heyning (Belgium), William Wijns (Ireland) The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online. ................................................................................................................................................................................................... Keywords Guidelines • adult congenital heart disease • aortopathies • arrhythmias • cancer • cardiomyopathy • car- diovascular risk factors • chronic coronary syndromes • exercise • heart failure • pregnancy • peripheral vascular disease • recommendations • risk stratification • sport À special environments • valvular heart disease . 4.2.5.3 Cardiac evaluation before exercise in Table of Contents . individualswithdiabetesmellitus............................ 20 Abbreviationsandacronyms........................................ 5 . 4.3Exerciseandsportsinageing ................................. 21 1Preamble......................................................... 6 . 4.3.1Introduction ............................................ 21 . 2Introduction...................................................... 8 . 4.3.2Riskstratification,inclusion/exclusioncriteria ............. 21 3 Identification of cardiovascular disease and risk stratification in . 4.3.3 Exercise modalities and recommendations for exercise and sport . individuals participating in recreational and competitive sports . 9 . intheelderly.................................................... 21 3.1Introduction ................................................. 9 . 5Exerciseinclinicalsettings........................................ 22 . 3.2 Definitions of recreational and competitive athletes . 9 . 5.1 Exercise programmes for leisure-time and competitive 3.3 Exercise-related major adverse cardiovascular events . 9 . sportparticipationinchroniccoronarysyndrome ................ 22 . 3.4 Incidence of sudden cardiac death in athletes . 10 . 5.1.1 Individuals at risk of atherosclerotic coronary artery 3.5 Aetiology of sudden cardiac death during exercise . 10 . disease and asymptomatic individuals in whom coronary . 3.6 Screening modalities for cardiovascular disease in young . arterydiseaseisdetectedatscreening ......................... 23 athletes......................................................... 10 . 5.1.1.1 Recommendations for sports participation . 23 3.7 Screening for cardiovascular disease in older athletes . 10 . 5.1.2 Established (long-standing) chronic coronary 4 Physical activity, leisure exercise, and competitive sports . syndrome.................................................... 24 participation ...................................................... 11 . 5.1.2.1Antithrombotictreatment........................... 26 4.1Generalintroduction ........................................ 11 . 5.1.3 Myocardial ischaemia without obstructive disease in 4.1.1 Definition and characteristics of exercise interventions . 11 . theepicardialcoronaryartery................................. 26 4.1.1.1Typeofexercise .................................... 11 . 5.1.4 Return to sport after acute coronary syndrome . 26 4.1.1.2Exercisefrequency.................................. 12 . 5.1.4.1Competitiveathletes................................ 26 4.1.1.3Exerciseintensity ................................... 12 . 5.1.4.2Recreationalathletes................................ 26 4.1.1.4Trainingvolume..................................... 12 . 5.1.5 Anomalous origin of coronary arteries . 26 4.1.1.5Typeoftraining ..................................... 12 . 5.1.5.1Background......................................... 26 4.1.2Classificationofexerciseandsports...................... 13 . 5.1.5.2Eligibilityforsports.................................. 26 4.2 Exercise recommendations in individuals with cardiovascular . 5.1.6Myocardialbridging...................................... 28 . riskfactors.....................................................