Exercise and Heart Disease

From Athletes and Arrhythmias to Hypertrophic Cardiomyopathy and Congenital Heart Disease

Abbas Zaidi; Sanjay Sharma


Future Cardiol. 2013;9(1):119-136. 

In This Article

Exercise Recommendations for Individuals With Heart Disease

Congenital & Inherited Conditions

Physical exertion may behave as a trigger for life-threatening ventricular arrhythmias in individuals harboring certain cardiac conditions, including the inherited cardiomyopathies and ion channel disorders. Restrictions on sporting activity are therefore recommended, such that individuals at greatest risk should be excluded from competitive sports in particular. The American College of Cardiology (ACC)[20] and the ESC[21] have issued recommendations for competitive sports participation in athletes with cardiovascular disease. The Mitchell classification[22] has traditionally been used to subdivide different sporting disciplines according to their static and dynamic components (Figure 2). The ESC advises that athletes with an established diagnosis of cardiomyopathy, or an ion channel disorder, such as the long QT or Brugada syndrome, should be excluded from competitive sports participation. Partial restriction is recommended for conditions such as moderate valvular lesions, such that sports with high static and high dynamic components are generally prohibited. No restrictions are advocated for athletes with minor congenital abnormalities, such as small atrial or ventricular septal defects, or mild valvular disease. It should be noted that a degree of discrepancy exists between the ESC and ACC recommendations. By way of example, the ACC places no restrictions on asymptomatic carriers of cardiomyopathy or ion channel disease mutations, whilst the ESC advises against competitive sports participation. Similarly, the ESC advises against competitive sports for individuals with the long-QT or Marfan syndromes, whilst the ACC recommendations permit low-intensity sports in long-QT syndrome, and low-to-moderate intensity sports in Marfan syndrome (in the absence of aortic root dilatation, mitral regurgitation, or family history of premature sudden death). Furthermore, the ESC mandates electrophysiological study in all cases of asymptomatic ventricular pre-excitation, whilst this is not a stipulation of the ACC recommendations. Despite these differences, both sets of guidance remain very similar in practice and in principle. Current European recommendations for the management of athletes with cardiovascular disease are summarized in Box 1.

Figure 2.

Classification of sports. Increasing dynamic component is defined in terms of estimated percentage of maximal oxygen uptake (peak VO2) achieved. Increasing static component relates to estimated percentage of MVC achieved in the skeletal muscles.
Danger of bodily collision. Increased risk if syncope occurs.
MVC: Maximal voluntary contraction.
Reproduced from [22] with permission of Journal of the American College of Cardiology.

Recommendations for leisure-time physical activity in members of the general population with cardiovascular conditions have also been issued.[23–26] These guidelines are much in accordance with those aimed at competitive athletes, such that activities with high static and high dynamic components are discouraged.

Exercise in the Cardiac Rehabilitation Setting

Despite the restrictions on intense physical activity recommended for individuals with a potentially arrhythmogenic condition, there is abundant evidence that regular, moderate physical activity is beneficial under certain circumstances, for example, in the cardiac rehabilitation setting for patients with established ischemic heart disease. A recent meta-analysis demonstrated reductions in mortality and re-infarction, as well as improvements in blood pressure, body weight and lipid profile in individuals engaging in an exercise-based cardiac rehabilitation program in the post-myocardial infarction setting.[27] It is recommended therefore that all patients that have experienced cardiac, and especially coronary, events or who are known to be affected by any asymptomatic cardiac disease should undergo exercise-related risk stratification and be offered a comprehensive cardiovascular rehabilitation program. Moderate-intensity aerobic physical activity of at least 30 min duration on most days of the week is advocated in order to yield a reduction in cardiac mortality in the region of 20–30%.[28]