14 Jun 2020 ESC guidelines on sports cardiology part 3
How exercise professionals can use the 2020 ESC guidelines part 3: aortopathies, hypertrophic cardiomyopathy, dilated cardiomyopathy, myocarditis, congenital heart disease
This is part three of a five-part series on the 2020 European Society of cardiology guidelines on sports cardiology. This topic includes summaries of exercise approaches for clients with the following conditions: aortopathies, hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, left ventricular non-compaction syndrome, dilated cardiomyopathy, myocarditis, and a generic approach to the many congenital heart diseases.
Aortopathies: this included the main conditions of aortic coarctations, aortic dissections and aortic aneurysms. Prior to engaging in exercise, risk stratification is needed with careful assessment including imaging of the aorta and exercise testing with BP measurements: it is important that BP within those arteries does not increase excessively during exercise and so BP should be significantly lower than the BP guidelines for apparently healthy individuals. Note: unfortunately, there are no guidelines published for exercise and aortopathies, and so we rely on clinical reasoning. Participation in individualised leisure exercise programs may be considered in high-risk individuals. Competitive sports are not recommended in individuals who are high-risk with aortopathies.
Hypertrophic cardiomyopathy: the main recommendations are that participation in high intensity exercise which includes HIIT, and some recreational and competitive sports are not recommended for individuals who have any markers of increased risk for follow-up. Annual medical follow-up is recommended for individuals who exercise on a regular basis; six monthly follow-ups should be considered in adolescent individuals and young adults who are still growing and more vulnerable to exercise related sudden cardiac death.
Left ventricular non-compaction syndrome (LVNC): a congenital condition where there is an increase in the amount of trabeculation in the left ventricle particularly lining the free wall and the apex of left ventricle; so, the epicardium is thinner. At rest and particularly during exercise, there are risks of arrhythmias and left ventricular ruptures. Participation in recreational exercise programs of low to moderate intensity may be considered in individuals with injection fraction of 40-49% in the absence of syncope +/- frequent +/- complex ventricular arrhythmias on ambulatory monitoring or exercise testing. Participation in high intensity exercise including HIIT and competitive sports may be considered for individuals who are gene positive for but phenotype negative. Participation in high intensity exercise in competitive sports is not recommended in individuals with any of the following symptoms: left ventricular ejection fraction < 40% +/- frequent +/- complex ventricular arrhythmias on ambulatory monitoring or exercise testing.
Dilated cardiomyopathy: participation in high or very high intensity exercise including competitive sports (with the exception of those where occurrence of syncope may be associated with harm or death) may be considered in asymptomatic individuals who fulfil all of the following criteria: (i) mildly reduced left ventricular function; (ii) absence of frequent +/- complex ventricular arrhythmias on ambulatory monitoring or exercise testing; (iii) absence of LGE on CMR; (IV) ability to increase ejection fraction by 10-15% during exercise and (V) no evidence of high-risk genotype.
Myocarditis: individuals with a probable or definite diagnosis of recent myocarditis are not recommended to engage in leisure time or competitive sports while active inflammation is present. Participation in moderate to high intensity exercise for a period of 3 to 6 months after acute myocarditis is not recommended. Participation in leisure exercise all competitive sports involving high intensity exercise in individuals with residual myocardial scar and persistent left ventricular dysfunction is not recommended.
Congenital heart disease: this is a very wide area to cover with so many different conditions. So, these recommendations are just a general recommendation that will obviously need to be targeted much more for each individual condition based on specific pathology, pathophysiology, and medical interventions. So, the ESC recommendations are based on a generic approach to congenital heart diseases: the first is that an individualised exercise prescription is recommended for every CHD patient. Assessments for ventricular function, pulmonary artery pressure, aortic size, and arrhythmia risks are recommended in all athletes with congenital heart disease. Competitive sports are not recommended for any individuals with congenital heart diseases who are in heart failure NYHA functional class III or IV and who have potentially serious arrhythmias.