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2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease

ESC Clinical Practice Guidelines

The current Guidelines for exercise and sports participation in individuals with CVD are the first of a kind by the ESC. Sports cardiology is a relatively novel and emerging sub-speciality, therefore the evidence base for the natural history of disease progression or risk of death during intensive exercise and competitive sport among individuals with CVD is relatively sparse.

The current Guidelines also draw upon existing ESC Guidelines for the investigation, risk assessment, and management of individuals with CVDs to aid physicians when prescribing exercise programmes or providing advice for sports participation.

In line with good clinical practice, the present document encourages shared decision making with the athlete patient and respects the autonomy of the individual after provision of detailed information about the impact of sports and the potential risks of complications and/or adverse events (Central illustration).

Preventive Cardiology
Exercise Testing
Sports Cardiology

Guidelines version available to download

  • Published in: 2020
    Reference doi:10.1093/eurheartj/ehaa605
  • Published in: 2021
  • Published in: 2020
    Reference TOC Pocket Guidelines
  • Published in: 2020
    Reference Pocket Guidelines App
  • Published in: 2020
    Reference 122 Slides

Table of contents: Full Text (ESC Clinical Practice Guidelines)

Abbreviations and acronyms



Identification of cardiovascular disease and risk stratification in individuals participating in recreational and competitive sports

  • Introduction
  • Definitions of recreational and competitive athletes
  • Exercise-related major adverse cardiovascular events
  • Incidence of sudden cardiac death in athletes
  • Aetiology of sudden cardiac death during exercise
  • Screening modalities for cardiovascular disease in young athletes
  • Screening for cardiovascular disease in older athletes

Physical activity, leisure exercise, and competitive sports participation

  • General introduction
  • Definition and characteristics of exercise interventions
  • Classification of exercise and sports
  • Exercise recommendations in individuals with cardiovascular risk factors
  • General introduction
  • Obesity
  • Hypertension
  • Dyslipidaemia
  • Diabetes mellitus
  • Exercise and sports in aging
    • Introduction
    • Risk stratification, inclusion/exclusion criteria
    • Exercise and sports indication and modalities

Exercise in clinical settings

  • Exercise programmes for leisure-time and competitive sport participation in chronic coronary syndrome
  • Individuals at risk of atherosclerotic coronary artery disease & asymptomatic individuals in whom coronary artery disease is detected at screening
  • Established (long-standing) chronic coronary syndrome
  • Myocardial ischaemia without obstructive disease in the epicardial coronary artery
  • Return to sport after acute coronary syndrome
  • Anomalous origin of coronary arteries
  • Myocardial bridging
  • Exercise recommendations in individuals with chronic heart failure
  • Background: rationale for exercise in chronic heart failure
  • Risk stratification and preliminary evaluation
  • Exercise modalities and sports participation in heart failure
  • Sports participation and return to sports
  • Heart failure with preserved ejection fraction
  • Exercise in individuals after heart transplantation
  • Exercise recommendations in individuals with valvular heart disease
  • Introduction
  • Aortic valve stenosis
  • Aortic valve regurgitation
  • Bicuspid aortic valve
  • Primary mitral regurgitation
  • Mitral stenosis
  • Tricuspid regurgitation
  • Exercise recommendations in individuals with aortopathy
  • Introduction
  • Risk of dissection
  • Sporting disciplines
  • Effect on aortic diameter and wall stress
  • Recommendations
  • Exercise recommendations in individuals with cardiomyopathies, myocarditis, and pericarditis
  • Hypertrophic cardiomyopathy
  • Arrhythmogenic cardiomyopathy
  • Exercise recommendations in individuals with left ventricular non-compaction
  • Exercise recommendations in individuals with dilated cardiomyopathy
  • Exercise recommendations in individuals with myocarditis and pericarditis
  • Exercise recommendations in individuals with arrhythmias & channelopathies
  • A general management framework
  • Atrial fibrillation
  • Supraventricular tachycardia and Wolff-Parkinson- White syndrome
  • Premature ventricular contractions and non-sustained ventricular tachycardia
  • Long QT syndrome
  • Brugada syndrome
  • Following device implantation
  • Exercise recommendations in individuals with adult congenital heart disease


  • The increasing numbers of athletes with congenital heart disease
  • Non-cardiac abnormalities in congenital heart disease and Paralympic sport
  • General considerations in the congenital heart disease athlete
  • Sudden death during sport
  • Exercise in athletes with congenital heart disease: current guidelines and recommendations
  • Assessment of the athlete with congenital heart disease

Key messages

Gaps in evidence

Sex differences

‘What to do’ and ‘what not to do’ messages from the Guidelines

Supplementary data