Recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology (EAPC) on sports-participation in patients with coronary artery disease (CAD), coronary artery anomalies (CAAs), or spontaneous dissection of the coronary arteries (SCAD), all associated with myocardial ischemia, and in patients with myocardial bridging (MB) have been updated.

Physical inactivity is a risk factor for CAD, and regular physical training lowers the risk of CAD and the risk of sudden cardiac death or arrest during vigorous exertion. Observational data have, however, also indicated that intensive exercise training increases the mortality risk in patients with CAD. Still, the actual incidence of acute events is very low, thus the benefits of regular physical activity and sport participation outweigh the risk for coronary events triggered by acute, intensive activity. Thus, leisure time activity is advised for all individuals with risk factors for, and with manifest CAD. The recommendations, when applied with reasonable precaution, ensure a high level of safety for all individuals with CAD.

In case of lack of scientific evidence, recommendations are based on clinical experience and expert opinion. The available classes and levels of evidence are given in the document. Below is a brief impression of the recommendations.

Asymptomatic athletes-patients with absence of clinically evident CAD:

• If there is no evidence of inducible ischemia on functional tests, participation in all types of exercise programs may be advised, including competitive sports, based on an individual careful evaluation.
• Effective risk factor management according to guidelines is mandatory.
• In athletes-patients risk factor profile and progression/regression of CAD should be periodically reassessed.

Athletes-patients with clinically proven CAD:

• Those at low risk for cardiac events are recommended to resume participation in competitive sports after minimum of three months after PCI.
• It is not recommended to participate in contact sports while the athlete-patient is under DAPT because of the risk of bleeding, but this may be considered afterwards.
• Eligibility assessment should always be combined with advising the athlete-patient on the correct approach to training.
• Performing a periodical cardiac evaluation is recommended, at least on a yearly basis.
• The risk factors should be properly managed with appropriate pharmacologic and lifestyle modifications, as they may affect the speed of progression of the atherosclerotic disease.
• Restrictions may be applied on an individual basis for certain sports with the highest CV demand because of high hemodynamic load and possible electrolyte imbalance.
• Older athletes-patients with CAD and low risk for cardiac events deserve special attention and a more cautious advice because of increased risk for SCD during endurance events in men >60 years.

Athletes-patients with non-CAD-related myocardial ischemia:

• Patients with congenital CAAs originating from the wrong sinus with acute angled take-off from the aorta and anomalous coursing between the aorta and the pulmonary artery are discouraged to participate in high-intensity sport prior to successful surgical correction. For those without inter-arterial course, an individualized approach for competitive sports participation is recommended.

All competitive sports are allowed in case of previous surgical correction and lack of persistent, inducible ischemia. In other types of CAA the absence of inducible ischemia should be confirmed and in this case no restriction exists regarding competitive sports participation.

• Further research is needed on sports participation in patients with SCAD. Meanwhile, intense competitive sports participation is discouraged because of an increased rate of recurrence in predisposed individuals and the potential for severe cardiac injury or death as consequence, whereas leisure time activity should be recommended individually.
• Asymptomatic athletes-patients with MB can participate in all competitive and leisure-time sports, because there is little evidence for exercise-induced harm in the absence of inducible effort-related ischemia or complex ventricular tachyarrhythmias. When therapy with beta-blockers fails in those with evidence of ischemia or symptoms, it is not recommended to participate in competitive sports and leisure-time activities should be properly advise.

You may also be interested in the following documents:

• The Study Group of Sports Cardiology simultaneously wrote recommendations for competitive sports participation in athletes with CVD.
• Simultaneously, EAPC published a position statement on competitive and leisure time sport in athletes with cardiomyopathies, myocarditis and pericarditis

Find the EAPC position statement on leisure time or competitive sports in those with CAD online at Eur Heart J