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Management of mature athletes with cardiovascular conditions
  1. Andrew D’Silva,
  2. Sanjay Sharma
  1. Clinical Cardiology and Academic Group, St George’s University of London,, London, UK
  1. Correspondence to Professor Sanjay Sharma, Cardiology Clinical and Academic Group, St George’s, University of London, Cranmer Terrace, London, SW17 0RE; sasharma{at}

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Learning objectives

  • To appreciate the benefits of exercise training and safety issues in exercise and sport.

  • To recognise the risk factors and mechanisms of sudden cardiac death during and after strenuous exercise with specific population challenges.

  • To understand the contraindications to exercise/sporting competition and the recommendations for professional and recreational sport participation.


Exercise is a potent therapy for the prevention1–4 and rehabilitation5 of cardiovascular disease, including the management of risk factors for atherosclerotic cardiovascular disease.6 It is important to recognise, however, that an ‘exercise paradox’ exists where vigorous physical activity transiently elevates the risk of sudden cardiac death (SCD) (figure 1). The risk is greatest in individuals who are not accustomed to regular exercise and undertake high intensity physical activity with little or no systematic training.7–9 

Figure 1

Exercise paradox. AF, atrial fibrillation; SCD, sudden cardiac death. Data taken from Nocon et al,1 Warburton et al,6 Marijon et al,17 Moore et al,2 McTiernan et al 3 and Hamer et al.4

In a previous review in the journal, we outlined the management of young competitive athletes with cardiovascular conditions.10 This population has been the main focus of attention for preparticipation screening,11 12 as the early detection of inherited cardiomyopathies and arrhythmic syndromes has the potential to prevent decades of lost life. Though widely debated,13 the methods of screening in this population are generally acceptable, and particularly the inclusion of an ECG is effective in detecting the majority of potentially fatal cardiac conditions relevant to this population.14 15

SCDs among young competitive athletes, however, account for just over 6% of all exercise-related SCDs.16 A far greater burden falls to non-elite, older athletes over 35 years of age, where the cause is overwhelmingly due to coronary artery disease …

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  • Contributors AD wrote the article. SS edited the article and provided critical review, also contributed original material to the final manuscript.

  • Competing interests AD was supported by a research grant from the charitable organization Cardiac Risk in the Young (CRY), which supports cardiovascular screening of young individuals. SS has been co-applicant on previous grants with CRY.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References marked with a * are key references for this paper.

  • Correction notice The corresponding authors address has been updated since this paper was first published online.