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

by Sabiha Gati and Thijs Eijsvogels, Sports Cardiology and Exercise Section

Rehabilitation and Sports Cardiology

Exercise recommendations in athletes have been described for the last two decades but these have been confined to elite athletes who are young and competitive and engage in highest echelons of sport. In contrast, the general population engages in recreational or solo exercise and these individuals have a higher prevalence of risk factors for coronary artery disease and cardiovascular abnormalities. It is known that exercise curbs risk factors for atherosclerosis but in addition to that it also reduces inflammation, modulates autonomic tone and improves tissue perfusion and by doing all of this it is associated with a reduction in cardiovascular morbidity and all-cause mortality. Due to the increasing prevalence of a sedentary lifestyle and emerging trend to obesity, hypertension and diabetes, physicians are being encouraged to promote exercise in all individuals including those with serious cardiovascular abnormalities. It is well recognised that the paradox of exercise is such that it may trigger an arrhythmogenic sudden cardiac death or myocardial infarction in a very small proportion of people with underlying cardiovascular concerns. Clearly as we try to promote exercise in everyone, there will be increasing questions and concerns amongst patients and clinicians as to what the correct and safe level of exercise is in any given individuals.

The ESC guidelines are the first to actually address exercise in all individuals. The aim of these guidelines is to strike the balance between the multiple benefits of exercise and also the small possibility of the risk of sudden cardiac death. In this respect the guidelines provide information on how to assess the disease process, the risk factors and also to identify the fitness level and ability of the individual before prescribing exercise. It is also important to emphasise that sports cardiology is a relatively novel field and therefore, the effect of intensive exercise on many diseases such as valvular heart disease, accessory pathways and heart muscle disease is not fully recognised in large cohorts.

Hence, these ESC guidelines truly recommend shared decision making whereby the attending cardiologist is honest about what is known and unknown and provides a satisfactory risk assessment before discussing the pros and cons of exercise in any given individual. These conversations should be documented clearly in the medical records.

The main highlights from the guidelines are as follows:

  1. Individuals with cardiovascular disease if able should engage in at least 150 minutes of moderate exercise per week over 5 days.
  2. Three sessions of resistance training per week has additional benefits in individuals who are obese, hypertensive or diabetic.
  3. Assessment of symptoms established risk factors and SCORE is recommended in people with risk factors for atherosclerosis.
  4. Risk stratification with functional ischaemia assessment is required for people considered high risk of an adverse cardiac events.
  5. Individuals with heart failure should have their medical therapy optimised with assessment of their functional capacity prior to prescribing an exercise program.
  6. Asymptomatic individuals with moderate valvular regurgitant lesions may participate in all sport provided they have a normal LV function, good functional capacity and absence of haemodynamic compromise.
  7. Asymptomatic individuals with mild hypertrophic cardiomyopathy and a low ESC risk score and the absence of markers of high risk may participate in all competitive sport.
  8. Individuals with active myopericarditis, arrhythmogenic cardiomyopathy and poor left ventricular function should not engage in intensive exercise.
  9. Regular exercise is fundamental for preventing atrial fibrillation, however, in older males, too much exercise may increase the risk of atrial fibrillation.
  10. Individuals with an internal cardiac defibrillator and those on anticoagulation should avoid contact sport.



Figure provided by Sabiha Gati


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)

Antonio Pelliccia, Sanjay Sharma, Sabiha Gati, Maria Bäck, Mats Börjesson, Stefano Caselli, Jean-Philippe Collet, Domenico Corrado, Jonathan A Drezner, Martin Halle et al., European Heart Journal, ehaa605,
29 August 2020

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology