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Highlights from the 2020 ESC guidelines on sport cardiology: practical management for safe sports and exercise in patients with cardiovascular disease
  1. Sabiha Gati1,
  2. Jonathan Drezner2,
  3. Sanjay Sharma3
  1. 1 Department of Cardiology, National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital NHS Foundation Trust, London, UK
  2. 2 Department of Family Medicine, University of Washington, Seattle, Washington, USA
  3. 3 Institute of Cardiovascular and Cell Sciences, St George’s University of London, London, UK
  1. Correspondence to Dr Sabiha Gati, Department of Cardiology, Imperial College London, London SW7 2BU, UK; s.gati{at}

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Habitual exercise provides unequivocal health benefits; however, exercise can also paradoxically trigger life-threatening arrhythmias in patients with underlying cardiovascular disease (CVD). Until recently, exercise recommendations for patients diagnosed with a pathological cardiac condition have focused mostly on competitive athletes participating in the highest echelons of sport.1 2 In contrast, over 90% of exercise-related sudden cardiac death occurs in the general population, usually affecting middle-aged and older men with atherosclerotic coronary artery disease. Over the past 25 years, there has been a surging increase in sedentary lifestyle associated with an increase in risk factors for atherosclerotic and other CVDs, which has demanded efforts to promote physical activity and systematic exercise in all patients.3 Such practice inevitably poses questions about the safe amount and intensity of exercise in patients with CVD, particularly those aspiring to engage in high-intensity exercise or sport.

The recent European Society of Cardiology (ESC) guidelines on sports cardiology and exercise in patients with CVD4 provide a foundation for cardiologists to assess and risk stratify individuals with potential or recognised CVDs who aspire to engage in more strenuous exercise. Given the sparse data on the impact of exercise on pathological substrates implicated in many CVDs, the guidelines advocate shared decision making and respect for patient autonomy after discussing the potential risk of complications or adverse events.4 This commentary highlights key recommendations for common cardiovascular conditions addressed in the ESC guideline (figure 1).

Figure 1

The what to ‘do’ and what ‘not to do’ in individuals with cardiovascular disease and gaps in knowledge. *Markers of increased risk include (1) cardiac symptoms or history of cardiac arrest or unexplained syncope, (2) moderate ESC risk score (>4%) at 5 years, (3) left ventricular outflow tract gradient at rest of >30 mm Hg, (4) abnormal blood pressure response to exercise and (5) …

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  • Contributors All authors have contributed equally to the planning, conduct and reporting of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.