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Inherited Cardiac Conditions reference

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Exercise and sport in inherited cardiac conditions

About These Recommendations

Exercise recommendations are based on ESC and AHA/ACC guidelines. The matrix below provides a quick reference for condition-specific recommendations. Detailed guidance follows.

Exercise Recommendation Matrix

Start from the baseline, not from the restrictions

The 2023 ESC cardiomyopathy guideline opens its exercise recommendations with two Class I statements that apply before any condition-specific restriction below: regular low- to moderate-intensity exercise is recommended in all able individuals with a cardiomyopathy, and an individualised risk assessment for exercise prescription is recommended in every patient. The matrix below qualifies that baseline for higher intensities and for competitive sport; it does not replace it. Deconditioning is a real harm, and a restriction should be a considered judgement about intensity, not a default.

Two consequences worth stating plainly. Where a row reads "Restricted", that generally means a weak recommendation requiring expert evaluation and shared decision-making, not a prohibition. Where it reads "Contraindicated", that reflects a genuine Class III statement in the source guideline for that condition.

Condition Low Intensity Moderate Intensity Vigorous Intensity Competitive Sport
HCM Permitted Restricted
Low-risk only		 Restricted
Low-risk, shared decision		 Restricted
Low-risk, expert evaluation
DCM Permitted Permitted
LVEF ≥50%; may be considered at LVEF 40–49%		 Restricted
May be considered if LVEF ≥50%, asymptomatic, optimally treated, no exercise-induced complex arrhythmia		 Restricted
Same conditions as vigorous; individualised
ACM Permitted Contraindicated Contraindicated Contraindicated
LQTS Permitted Restricted
Depends on type		 Restricted
Type & treatment dependent		 Restricted
Specialist review, on therapy
Brugada Permitted Permitted
Avoid dehydration		 Restricted
If asymptomatic		 Restricted
Asymptomatic: shared decision
CPVT Permitted Contraindicated Contraindicated Contraindicated
Marfan/TAAD Permitted Restricted
Root <40mm, non-contact		 Contraindicated
All root sizes (ESC 2020)		 Contraindicated
Contact/collision
Gene +ve / Pheno -ve
HCM		 Permitted Permitted Permitted
ESC 2023 Class IIa		 Permitted
ESC IIa / AHA 2a; annual review
Gene +ve / Pheno -ve
DCM / NDLVC		 Permitted Permitted
ESC 2023 Class IIa		 Permitted
Except LMNA, TMEM43		 Restricted
Shared decision
Gene +ve / Pheno -ve
ARVC		 Permitted Permitted Restricted
Avoidance may be considered (IIb)		 Restricted
Avoidance may be considered (IIb)

Sources: ESC 2020 Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease (Pelliccia A et al. Eur Heart J. 2021;42:17–96) · ESC 2023 Guidelines for the Management of Cardiomyopathies (Arbelo E et al. Eur Heart J. 2023;44:3503–3626) · ESC 2022 Guidelines on Ventricular Arrhythmias and SCD · AHA/ACC 2024 Guideline for the Management of Hypertrophic Cardiomyopathy (Ommen SR et al. J Am Coll Cardiol. 2024;83:2324–2405), which supersedes the 2015 AHA/ACC competitive-athlete recommendations for HCM. Where the European and American guidelines differ, both positions are given in the condition sections below. Recommendations should be interpreted in the context of individual clinical assessment and local multidisciplinary team guidance.

Exercise Intensity Definitions

Light/Low Intensity

  • MET: <3 METs
  • Heart rate: <50% max HR
  • Examples: Walking slowly, bowling, golf (with cart), light housework
  • Can hold conversation easily

Moderate Intensity

  • MET: 3-6 METs
  • Heart rate: 50-70% max HR
  • Examples: Brisk walking, recreational swimming, cycling on flat terrain, doubles tennis, golf (carrying clubs)
  • Can talk but not sing

Vigorous Intensity

  • MET: >6 METs
  • Heart rate: 70-85% max HR
  • Examples: Running, singles tennis, competitive cycling, football, basketball, vigorous swimming
  • Difficult to talk comfortably

Competitive Sport

  • Organized team or individual sports
  • Regular training and competition
  • Performance-focused
  • Examples: Any sport at club, regional, or national level

Detailed Condition-Specific Recommendations

Hypertrophic Cardiomyopathy (HCM)

PERMITTED

  • Low intensity recreational exercise (walking, golf with cart, bowling)
  • Moderate intensity if low-risk (recreational swimming, doubles tennis, recreational cycling)
  • Light resistance training (<50% MVC)
  • Vigorous or competitive sport may be considered in selected low-risk patients after comprehensive evaluation and shared decision-making (2024 AHA/ACC)

CONTRAINDICATED

  • Competitive or vigorous sport in patients with high-risk features (see below)
  • High intensity exercise (running, intense cycling, vigorous swimming)
  • High static component sports (weightlifting, gymnastics)
  • Marathon, triathlon, CrossFit

Special considerations: Avoid activities that worsen LVOT gradient (Valsalva, post-exercise). Low-risk patients (no LVOTO, thinner walls, no high-risk features) may engage in moderate-intensity activities after shared decision-making.

High-risk features (any of the following warrant exercise restriction): Prior exertional syncope/presyncope, sustained VAs or cardiac arrest, family history of SCD in young relatives, severe LVH (≥30mm), extensive LGE (≥15% LV mass), severe LVOT obstruction (>50mmHg), apical aneurysm, LVEF <50%, NSVT, abnormal BP response to exercise, or HCM Risk-SCD ≥6%.

Dilated Cardiomyopathy (DCM)

PERMITTED

  • Low intensity exercise (all patients)
  • Moderate intensity if LVEF >35-40% and stable
  • Vigorous exercise if LVEF >50%, stable, no arrhythmias
  • Competitive sport only if LVEF >50%, no LGE, normal exercise test

CONTRAINDICATED

  • Competitive sport if LVEF <50%
  • Vigorous exercise if LVEF <45% or symptomatic
  • Any exercise during acute decompensation

Special considerations: Exercise capacity improves with appropriate medical therapy. Annual assessment recommended. LMNA mutations require careful monitoring regardless of LVEF.

Arrhythmogenic Cardiomyopathy (ACM)

PERMITTED

  • Low intensity recreational exercise only (walking, golf with cart)

GENERALLY AVOIDED

  • Competitive sports
  • Moderate-vigorous intensity exercise
  • Endurance exercise (running, cycling, swimming)
  • Moderate-intensity recreational activity may be considered after specialist review and shared decision-making

Special considerations: Exercise can accelerate disease progression in ARVC ("exercise paradox"). Even moderate exercise may worsen phenotype. Among the stricter restrictions of the cardiomyopathies, though individualized after specialist assessment rather than an absolute rule.

Long QT Syndrome (LQTS)

PERMITTED

  • Low intensity exercise (all genotypes)
  • Moderate intensity if on therapy, asymptomatic, QTc <500ms
  • LQT3: Generally more permissive (avoid rest/sleep triggers)
  • Competitive sport may be considered after LQTS-specialist review if on therapy, no recent arrhythmic syncope, with an emergency action plan/AED (ESC 2020)

GENERALLY AVOIDED

  • Competitive sport without specialist evaluation, optimised therapy, and an emergency action plan
  • Unsupervised swimming/diving is a recognised LQT1 trigger; specialist evaluation, treatment adherence and shared decision-making guide whether supervised swimming can be permitted, rather than a lifetime blanket prohibition
  • High intensity exercise (especially LQT1)

Genotype-specific: LQT1, caution with swimming/diving. LQT2, minimise sudden loud alarms/auditory triggers. LQT3, more permissive for exercise (events at rest/sleep). Beta-blocker therapy is foundational where tolerated; specialist alternatives are used for those with intolerance or contraindications. All of this should be individualised through specialist risk assessment.

Brugada Syndrome

PERMITTED

  • Low-moderate intensity exercise if asymptomatic
  • Vigorous exercise if asymptomatic Type 1 pattern only
  • Competitive sport possible if asymptomatic, shared decision-making

CONTRAINDICATED

  • Competitive sport if history of syncope or VF
  • Exercise in febrile illness (aggressive fever management essential)
  • Avoid dehydration and excessive alcohol

Special considerations: Events typically at rest/sleep (not during exercise). More permissive than other channelopathies for asymptomatic patients. Fever is major trigger - treat aggressively.

Catecholaminergic Polymorphic VT (CPVT)

PERMITTED

  • Low intensity exercise only if well-controlled on therapy

CONTRAINDICATED

  • Competitive sports: strict avoidance
  • Moderate-vigorous exercise
  • Swimming
  • Any intense physical or emotional stress

Special considerations: CPVT is exercise/catecholamine-triggered - among the strictest exercise restrictions of the channelopathies. Even on high-dose beta-blockers + flecainide, avoid moderate-vigorous exercise; low-intensity recreational activity may be individualised after specialist assessment. Compliance with therapy is critical.

Marfan Syndrome & Thoracic Aortic Aneurysm Disease (TAAD)

PERMITTED

  • Low intensity exercise (all patients)
  • Moderate intensity if aortic root <40mm
  • Non-contact sports if aortic dimensions stable

CONTRAINDICATED

  • Contact/collision sports (rugby, boxing, martial arts)
  • Isometric exercise (weightlifting)
  • Competitive sport if aortic root >40mm
  • Vigorous intensity if aortic root >40mm

Special considerations: Exercise restrictions based on aortic dimensions. Annual imaging essential. Loeys-Dietz more aggressive (lower thresholds). Avoid Valsalva maneuvers and activities that spike blood pressure.

Genotype-Positive / Phenotype-Negative (G+/P-)

There is no single rule for genotype-positive, phenotype-negative individuals. The 2023 ESC cardiomyopathy guideline gives a different recommendation for each phenotype, and the underlying gene matters.

PERMITTED

  • HCM: high-intensity exercise and competitive sport should be considered in those who seek to do so (ESC 2023 Class IIa). The 2024 AHA/ACC HCM guideline agrees, rating participation in competitive sport of any intensity as reasonable (Class 2a)
  • DCM and NDLVC: moderate- and high-intensity exercise should be considered (ESC 2023 Class IIa), with the explicit exception of pathogenic LMNA and TMEM43 variants
  • All phenotypes: regular low- to moderate-intensity exercise is recommended (ESC 2023 Class I), as it is for every able individual with a cardiomyopathy

REQUIRES INDIVIDUAL ASSESSMENT

  • ARVC families: avoidance of high-intensity exercise, including competitive sport, may be considered (ESC 2023 Class IIb). This is a weak recommendation rather than a prohibition, and the guideline does not distinguish by gene for ARVC
  • LMNA and TMEM43 variant carriers are named exceptions to the permissive DCM and NDLVC recommendation above, and should be assessed individually
  • Channelopathy genotypes (e.g. RYR2 in CPVT, exercise-triggered LQTS genotypes) are covered by the 2022 ESC ventricular arrhythmia guideline, not the cardiomyopathy guideline, and are handled in those condition sections

Surveillance: exercise permission does not change the need to watch for phenotype conversion. ESC recommends annual assessment where competitive sport is undertaken; otherwise follow that condition's usual screening interval (see its Follow-up section). Routine ambulatory ECG and exercise testing are not required in phenotype-negative individuals unless the family history indicates high risk or they form part of pre-participation screening (2024 AHA/ACC).

Special considerations: the decision should involve the patient, the cardiologist and, where relevant, a sports physician. Gene- and variant-specific risk assessment matters more here than the phenotype label alone.

General Exercise Guidance

Shared decision-making: All recommendations individualized with patient and specialist input.

Regular review: Annual reassessment of exercise capacity and recommendations.

Adequate treatment: Optimize medical therapy before exercise.

Warning signs: Stop immediately if chest pain, palpitations, breathlessness, dizziness, or syncope.

Emergency plan: Patients and families should know CPR and have access to emergency services.

Key References:

  • 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease
  • 2023 ESC Guidelines for the Management of Cardiomyopathies
  • 2022 ESC Guidelines on Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death
  • 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy