2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease
We have completed guidelines recommendation for “Exercise recommendations in individuals with valvular heart disease” in December month. Moving forward in this 2020 ESC guidelines, we are going to summarize guidelines for “Exercise recommendations in individuals with aortopathy and cardiomyopathies” this month.
The author Antonio Pelliccia, Sanjay Sharma and other members of the European Society of Cardiology (2020) have come up with exercise recommendation in different types of cardiac problems.
Objective:
To provide safe and evidence-based exercise programs for a patient with aortopathy and cardiomyopathies.
Method:
The currently available evidence and scientific and medical knowledge helped with the development of the guidelines. The selected articles were later classified and graded depending on the usefulness/ efficacy of the procedure and methodology of clinical trials.
Recommended guidelines:
• Risk classification to perform sports in patients with aortic pathology
1) LOW RISK
Diagnosis: aorta < 40mm in bicuspid aortic valve (BAV) or tricuspid valve, turner syndrome without aortic dilation
Advice: all sports permitted with a preference for endurance overpower sports
Follow-up: every 2-3 years
2) LOW-INTERMEDIATE RISK
Diagnosis: Marfan syndrome (MFS) or other Hereditary thoracic aortic disease (HTAD), aorta 40-45 mm in BAV/ tricuspid valve, after successful thoracic aorta surgery for BAV/ other low-risk situation
Advice: avoid high and very high-intensity exercise, contact, and power-sports. Preference for endurance over power-sports.
Follow-up: every 1-2 years
3) INTERMEDIATE RISK
Diagnosis: Moderate aortic dilation (40-45 mm in MFS or other HTAD, 45-50 mm in BAV/ tricuspid valve, turner syndrome Aortic size index (ASI),
20-25mm/m2, tetralogy of Fallot < 50mm), after successful thoracic aorta surgery for MFS/HTAD
Advice: only skill sports or mixed or endurance sports at low intensity
Follow-up: every 6 months to 1 year
4) HIGH RISK
Diagnosis: severe aortic dilation (>45mm in MFS or other HTAD, >50mm in BAV or tricuspid valve, turner syndrome ASI >25mm / m2, tetralogy of Fallot > 50mm), after surgery with sequelae
Advice: sports are (temporarily) contra-indicated
Follow-up: re-evaluation after treatment
• Recommendations for exercise and participation in sports in individuals with aortic pathology
Conduct assessment of risk stratification by including advanced imaging of the aorta (CT/CMR) and exercise testing with blood pressure assessment, before engaging in exercise.
Regular follow-up including risk assessment is recommended.
Dynamic exercise should be considered more suitable than static exercise.
Participation in competitive or leisure-time sports activities (except power sports) should be considered in low-risk individuals.
Participation in individualized leisure exercise programs may be considered in high-risk individuals.
In high-risk individuals, Competitive sports are not recommended.
• Recommendations for exercise and sports participation in individuals with hypertrophic cardiomyopathy
Exercise recommendation is as follow:
Participation in high-intensity exercise/competitive sports, if desired (except for those where the occurrence of syncope may be associated with harm or death), may be considered for individuals who do not have any markers of increased risk following expert assessment.
Participation in low- or moderate-intensity recreational exercise, if desired, may be considered for individuals who have any markers of increased risk following expert assessment.
Participation in all competitive sports, if desired, may be considered for individuals who are gene-positive for Hypertrophic cardiomyopathy (HCM) but phenotype negative.
Participation in high-intensity exercise (including recreational and competitive sports) is not recommended for individuals who have ANY markers of increased risk.
Follow-up and further considerations relating to risk are as follow:
Annual follow-up is recommended for individuals who exercise regularly.
Six-monthly follow-up should be considered in adolescent and young adults who are more vulnerable to exercise-related Sudden cardiac death (SCD).
Annual assessment should be considered for genotype-positive/phenotype-negative individuals for phenotypic features and risk stratification purposes.
• Recommendations for exercise and sports participation in individuals with arrhythmogenic cardiomyopathy
Exercise recommendations are as follow:
Participation in 150 min of low-intensity exercise per week should be considered for all individuals.
Participation in low- to moderate-intensity recreational exercise/sports, if desired, may be considered for individuals with no history of cardiac arrest/ Ventricular arrhythmia (VA), unexplained syncope, minimal structural cardiac abnormalities, <500 Premature ventricular contractions (PVCs)/24 h and no evidence of exercise-induced complex VAs.
Participation in high-intensity recreational exercise/ sports or any competitive sports is not recommended in individuals with Arrhythmogenic cardiomyopathy (ACM), including those who are gene-positive but phenotype negative.
Follow-up and further considerations relating to risk are as follow:
Annual follow-up is recommended for individuals who exercise regularly.
Six-monthly follow-up should be considered in adolescent individuals and young adults who are more vulnerable to exercise-related SCD.
Annual assessment should be considered for genotype-positive/phenotype-negative individuals for phenotypic features and risk stratification purposes.
Six-monthly follow-up should also be considered in individuals with high arrhythmic risk genotypes such as DSP, TMEM43, and carriers of multiple pathogenic variants.
• Recommendations for exercise in individuals with left ventricular non-compaction cardiomyopathy
A diagnosis of LVNC in athletic individuals should be considered if they fulfil imaging criteria, in association with cardiac symptoms, family history of LVNC or cardiomyopathy, left ventricular (LV) systolic (EF<50%) or diastolic (E’<9 cm/s) dysfunction, a thin compacted epicardial layer (<5 mm in end-diastole on cardiac magnetic resonance (CMR), or <8 mm in systole on echocardiography), or abnormal 12-lead ECG.
Exercise recommendations are as follow:
Participation in high-intensity exercise and all competitive sports, if desired, with the exception where syncope may cause serious harm or death, may be considered in asymptomatic individuals with left ventricular non-compaction (LVNC) and left ventricular ejection fraction (LVEF) ≥50% and absence of frequent and/or complex ventricular arrhythmia (VAs).
Participation in recreational exercise programs of low to moderate intensity, if desired, may be considered in individuals with LVEF 40-49% in the absence of syncope and frequent or complex VAs on ambulatory Holter monitoring or exercise testing.
Participation in high- or very high-intensity exercise including competitive sports, if desired, may be considered for individuals who are gene-positive for LVNC but phenotype negative (except for lamin A/C or filamin C carriers).
Participation in high-intensity exercise or competitive sports is not recommended in individuals with any of the following: symptoms, LVEF<40%, and/or frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing.
Follow-up and further considerations are as follow:
The annual assessment for risk stratification is recommended for individuals with LVNC and genotype positive/phenotype-negative individuals who exercise regularly.
• Recommendations for exercise in individuals with dilated cardiomyopathy
Participation in low- to moderate-intensity recreational exercise should be considered in all individuals with DCM, regardless of the EF, in the absence of limiting symptoms, and exercise-induced VAs.
Participation in high- or very high-intensity exercise including competitive sports (except for those where the occurrence of syncope may be associated with harm or death) may be considered in asymptomatic individuals who fulfil all of the following:
(i) mildly reduced LV systolic function (EF 4550%);
(ii) absence of frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing;
(iii) absence of LGE on CMR;
(iv) ability to increase EF by 1015% during exercise; and
(v) no evidence of high-risk genotype (lamin A/C or filamin C).
Participation in all competitive sports may be considered in individuals with DCM who are genotype positive and phenotype negative, except for carriers of high-risk mutations (lamin A/C or filamin C).
Participation in high- or very high-intensity exercise including competitive sports is not recommended for individuals with a DCM and any of the following:
(i) symptoms or history of cardiac arrest or unexplained syncope;
(ii) LVEF<45%;
(iii) frequent and/or complex VAs on ambulatory Holter monitoring or exercise testing;
(iv) extensive LGE (>20%) on CMR; or
(v) high-risk genotype (lamin A/C or filamin C).
Follow-up recommendations are as follow:
Annual follow-up is recommended for individuals with DCM who exercise regularly
Six-monthly follow-up should be considered in individuals with high-risk mutations and adolescent individuals and young adults whose DCM phenotype may still be evolving and who are more vulnerable to exercise-related SCD.
Annual assessment should be considered for genotype-positive/phenotype-negative individuals for phenotypic features and risk stratification purposes.
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