2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease
We have completed guidelines recommended for “Exercise recommendations in individuals with myocarditis and pericarditis” in the month of February. While moving forward in this 2020 ESC guidelines, we are going to summarize guidelines for “Exercise recommendations in individuals with arrhythmias and channelopathies” this month.
Objective:
To provide safe and evidence-based exercise programs for a patient with arrhythmias and channelopathies.
Method:
The guideline was developed from the currently available evidence and scientific and medical knowledge. The selected articles were later classified and graded depending on the usefulness/ efficacy of the procedure and methodology of clinical trials.
Recommended guidelines:
Recommendations for exercise in individuals with atrial fibrillation (AF)
• In order to prevent AF, regular physical activity is recommended.
• Before engaging in sports, evaluation and management of thyroid dysfunction, structural heart disease, alcohol or drug abuse, or other primary causes of AF is recommended.
• In middle-aged men with AF who exercise vigorously, counseling about the effect of long-lasting intense sports participation on the recurrence of AF is recommended.
• In exercising individuals with recurrent symptomatic AF, and/ or in those who do not want drug therapy AF ablation is recommended, given its impact on athletic performance.
• The AF individual should consider the ventricular rate while exercising and titrated rate control should be introduced.
• Individuals with well-tolerated AF and those without structural heart disease should consider participating in sports without antiarrhythmic therapy.
• To prevent atrial flutter 1: 1 atrioventricular conduction, cavotricuspid isthmus ablation should be considered in those with documented flutter who want to engage in intensive exercise.
• For individuals with AF who want to engage in intensive exercise and in whom class I drug therapy is initiated, prophylactic cavotricuspid isthmus ablation should be considered to prevent flutter.
• It is not recommended to use class I antiarrhythmic drugs as monotherapy during vigorous exercise without proof of adequate rate control of AF/ atrial flutter (AFL).
• Until two half-lives (i.e. up to 2 days) of the antiarrhythmic drug have elapsed after ingestion of pill-in-the-pocket flecainide or propafenone, participation in intensive sports is not recommended.
• In individuals with AF who are anticoagulated, sports with direct bodily contact or prone to trauma are not recommended.
Recommendations for exercise and sports participation in individuals with paroxysmal supraventricular tachycardia and pre-excitation
• A comprehensive assessment is recommended to exclude structural heart disease, pre-excitation, and VAs, in individuals with palpitations.
• Participation in all sports activities is recommended in individuals with paroxysmal supraventricular tachycardia (PSVT) without preexcitation.
• In recreational and competitive athletes with pre-excitation and documented arrhythmias, ablation of the accessory pathway is recommended
• An electrophysiological (EP) study is recommended to evaluate the risk for sudden death, in competitive/professional athletes with asymptomatic pre-excitation.
• Curative treatment by ablation should be considered, in competitive athletes with PSVT but without pre-excitation.
Recommendations for exercise in individuals with premature ventricular contractions or non-sustained ventricular tachycardia
• A thorough evaluation with a detailed family history should be included to exclude underlying structural or arrhythmogenic conditions, in exercising individuals with >_2 premature ventricular contractions (PVCs) on a baseline ECG or >_1 PVC in the case of high-endurance athletes.
• A thorough investigation with exercise test, Holter monitoring, 12-lead ECG, and suitable imaging is recommended, among individuals with frequent PVCs and Non sustained ventricular tachycardia (VT).
• After periodic re-evaluation in individuals without familial or structural underlying disease, all competitive and leisure-time sports activities are permitted.
Recommendations for exercise in long QT syndrome (LQTS)
• Therapy with beta-blockers at the target dose is recommended for all exercising individuals with LQTS with prior symptoms or prolonged QTc.
• QT-prolonging drugs and electrolyte imbalance such as hypokalemia and hypomagnesemia should be avoided in exercising individuals with LQTS.
• In patients with genotype-positive/phenotype-negative LQTS (i.e. <470/480 ms in men/women), shared decision-making should be considered regarding sports participation. Type of mutation, type and setting of sports, and extent of precautionary measures should be considered in this context.
• In individuals with a QTc>500 ms or a genetically confirmed LQTS with a QTc>_470 ms in men or >_480 ms in women, participation in high-intensity recreational and competitive sports, even if the patient is on beta-blockers, is not recommended.
• In individuals with LQTS and prior cardiac arrest or arrhythmic syncope, participation in competitive sports (with or without ICD) is not recommended.
Recommendations for exercise in Brugada syndrome (BrS)
• In patients with BrS with episodes of arrhythmic syncope and/or aborted sudden cardiac death (SCD), implantable cardioverter-defibrillator (ICD) implantation is recommended.
• In individuals who have not experienced recurrent arrhythmias over 3 months after ICD implantation, resumption of leisure or competitive sports should be considered after shared decision making.
• Participation in sports activities that are not associated with an increase in core temperature >39C may be considered, in asymptomatic individuals with BrS, asymptomatic mutation carriers, and asymptomatic athletes with only an inducible ECG pattern.
• In individuals with overt BrS or phenotypically negative mutation carriers, prescription of drugs that may aggravate BrS, electrolyte abnormalities, and sports practice that increases core temperature >39 C are not recommended.
Recommendations for exercise in individuals with pacemakers and implantable cardioverter defibrillators
• It is recommended that individuals with underlying disease and implanted devices with/without resynchronization follow the recommendations pertaining to the underlying disease.
• In individuals with pacemaker therapy who do not have pathological substrates for fatal arrhythmias, participation in sports and exercise (except collision sports) should be considered.
• Prevention of direct impact to the implanted device should be considered by adapting the site of lead and/or device implantation, padding, or restricting direct impact sports.
• To allow appropriate tailoring of rate-responsive pacing parameters, exclusion of myopotential or electromagnetic inhibition, and detection of VAs, Holter recordings, and device interrogation during and after resuming sports should be considered.
• In individuals with an ICD, taking into account the effect of sports on the underlying substrate, the fact that intensive sports will trigger more appropriate and inappropriate shocks, the psychological impact of shocks on the athlete/patient, and the potential risk for third parties, shared decision making should be considered during decisions relating to continuation of intensive or competitive sports participation.
• An ICD is not recommended as a substitute for disease-related recommendations when these mandate sports restrictions
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