Abstract
Introduction
Regular physical activity is advised as a therapeutic procedure for several cardiovascular diseases and has been advocated as a major determinant for reducing the impact of cardiovascular (CV) risk factors [1–3]. Indeed, leisure sport activities have become an integral part of the lifestyle in a vast proportion of western populations, with an increasing participation by individuals of different ages, including a substantial proportion of subjects with inherited and acquired pathologic cardiovascular conditions.
The regular involvement in exercise training and sport activities by individuals with a broad spectrum of cardiovascular abnormalities raises a number of clinical and ethical questions, including the advise for safe and prudent sport participation, namely, how to attain the benefits derived from an athletic lifestyle without incurring the risks of inappropriate exercise training.
In clinical practice, diagnosis of cardiovascular disease, or incidence of cardiac events are often associated with the medical advise for patients to leave intensive exercise training and sport participation, with the aim being to protect these individuals from the hazards of inappropriate exercise. Recent scientific evidence [4–6] supports the wide clinical perception that individuals with underlying (even clinically silent) CV disease have an increased risk for sudden cardiac death (SCD), or clinical deterioration in association with exercise training and sports.
Therefore, physicians face the paradox of whether to withdraw their patients from a potentially useful therapeutic procedure. Indeed, the physical and mental benefits associated with physical activity and sport are so profoundly perceived by patients, that any limitation in their exercise regimen is poorly accepted and often disregarded.
To resolve this controversial clinical issue, which has relevant practical implications in a large proportion of cardiac patients, the Study Group of Sports Cardiology of the European Society of Cardiology (ESC) prompted publication of the present ‘Recommendations', with the aim to provide careful guidelines to physicians and consultant cardiologists concerning the evaluation of patients with CV disease and appropriate recommendations for safe sport participation.
These recommendations assume that a cardiac diagnosis has already been made, so that the issues directly related to screening and identification of CV disease [7] are beyond the scope of this document.
The nature of the recommendations
The present recommendations represent a consensus document from an international panel of experts appointed by the ESC, including clinical CV specialists with experience in exercise physiology, sports medicine and clinical cardiology. The present recommendations are based on published scientific evidence, when available, and on personal experience and consensus of experts. However, in consideration of the scarcity of scientific investigations concerning the effect of regular exercise training and sport activities on the clinical course of several CV diseases, the panel acknowledges the difficulties inherent in formulating arbitrary recommendations, particularly for those CV diseases in which scientific evidence is scarce.
Therefore, caution in applying the present document is needed, and efforts should be made to tailor precise advice to each patient.
The aim of the panel was to formulate directions that represent a reasonable balance between the risks and the benefits inherent with exercise and sports; the present recommendations represent, therefore, a prudent, contemporary, and practical document for advising exercise and sports activity in patients with CV disease.
The role of the examining physician
The role of examining physician is to provide careful assessment and appropriate suggestions regarding the exercise program or sport activity, which are more suitable for the candidate with CV disease and suggest, if necessary, the appropriate drug therapy. Furthermore, the examining physician (and consultant cardiologist) have the ethical, medical and legal obligation to exhaustively inform the candidate of the risks inherent with exercise training and an athletic lifestyle and, when the CV risk appears to be disproportionately high, the physician should suggest that the patient withdraws from intensive exercise training and sport, with the aim of preventing adverse clinical events and/or reduce the risk for disease progression. This recommendation may be particularly true in cases of competitive sport activities. In fact, due to the unique structure and pressures of competitive sports, individuals with CV disease may not always use proper, independent judgment in assessing the overall risk associated with a competitive athletic lifestyle. These recommendations are intended, therefore, to support the physician's decision in such difficult instances and offer the patients a sort of medical protection from the unsustainable hazard of competitive sports.
Although vigorous exercise and competitive sport may increase the risk of a cardiovascular event, the benefits of physical activity by far outweigh the dangers. This is the basis for recommending an appropriate level of physical activity in most patients, specifically those with coronary artery disease (CAD), systemic hypertension and diabetes. Considerable epidemiological evidence (albeit no random-assignment and controlled studies), support the concept that regular physical activity, including vigorous activity, is associated with a reduced rate of CAD events [8, 9].
It should also be noted that most subjects dying suddenly during exercise had reported previous symptoms that were often misinterpreted and so had not raised any medical attention. Consequently, physicians should carefully evaluate subtle cardiac symptoms in physically active individuals. Both physicians and patients should also be aware that vigorous exercise per se does not exclude the presence of cardiovascular disease and that high levels of fitness do not protect against the incidence of cardiac events.
Classification of sports
A classification of the different sports is provided in Table 1. Sports activities are classified into two main categories (i.e., dynamic and static) and intensity is roughly divided into low, moderate and high. This classification is intended to provide a schematic indication of the CV demand associated with different sports, with an additional notification of those disciplines associated with increased risk of bodily collision and those associated with an enhanced risk if syncope occurs (which should be avoided in certain cardiac patients).
Classification of sports †
∗ Danger of bodily collision.
‡ Increased risk if syncope occurs.
† Adapted and modified from Mitchell et al. Classification of Sports. JACC 1994;
Implementation of the recommendations within European countries
Although large differences are present at the moment among the European countries regarding the standards of medical care, a substantial homogeneity exists throughout Europe with regard to cultural background and social attitudes towards medicine, which will facilitate any implementation of a common strategy for advising physical activity and sport participation in patients with CV disease [10].
This panel advises that the present ‘Recommendations’ represent the standard of medical care for the evaluation of patients with CV disease willing to be engaged in regular exercise and competitive sport. The present consensus document may be of relevant medical (and legal) value for physicians required to assess exercise capacity and establish the participation of patients with CV disease in competitive sport. Adherence to these recommendations will have a substantial and cost-effective impact on medical care by enhancing the safety of athletic activities and reducing the legal controversies related to different (or lack of) regulations.
This panel also acknowledges that implementation of the present recommendations throughout Europe (along with the necessary support of the national scientific societies and official sport organizations within each country) will likely take some time, bearing in mind the different cultural and social backgrounds.