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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 127-138

A Narrative Review on Exercise and Cardiovascular Events: “Primum Non Nocere”

1 First Cardiology Clinic, Medical School, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece
2 3rd Department of Cardiology, School of Medicine, Sotiria Chest Disease Hospital, National and Kapodistrian University of Athens, Athens, Greece
3 Athens Heart Center, Athens Medical Center, Athens, Greece

Date of Submission10-Aug-2022
Date of Acceptance09-Sep-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Kyriakos Dimitriadis
Dardanellion 146-148, Athens, 17123
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_25_22

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Exercise provides beneficial effects on the primary and secondary prevention of numerous chronic conditions, including cardiovascular disease, diabetes mellitus, and malignancies. Despite its indisputable benefits, exercise can rarely trigger major adverse cardiovascular events such as ventricular arr hythmias, myocardial infarction, or even sudden cardiac arrest in susceptible individuals. Physiological changes that occur during exercise, including increased sympathetic activity and cardiac oxygen requirements, may account for ischemia and trigger ventricular ectopy with eventually adverse outcomes. Tailored preparticipation screening for exercise and sports engagement is fundamental to unveiling underlying pathological conditions. The present review summarizes the overall impact of exercise on cardiovascular health and highlights the recommended prevention strategies.

Keywords: Cardiovascular disease, exercise, prevention, training programs

How to cite this article:
Dimitriadis K, Bletsa E, Lazarou E, Leontsinis I, Stampouloglou P, Dri E, Sakalidis A, Pyrpyris N, Tsioufis P, Siasos G, Tsiachris D, Tsioufis K. A Narrative Review on Exercise and Cardiovascular Events: “Primum Non Nocere”. Heart Mind 2022;6:127-38

How to cite this URL:
Dimitriadis K, Bletsa E, Lazarou E, Leontsinis I, Stampouloglou P, Dri E, Sakalidis A, Pyrpyris N, Tsioufis P, Siasos G, Tsiachris D, Tsioufis K. A Narrative Review on Exercise and Cardiovascular Events: “Primum Non Nocere”. Heart Mind [serial online] 2022 [cited 2023 Mar 29];6:127-38. Available from: http://www.heartmindjournal.org/text.asp?2022/6/3/127/357546

  Introduction Top

The positive impact of exercise on the primary and secondary prevention of numerous chronic conditions, including cardiovascular disease (CVD), diabetes mellitus, and several malignancies, among others, has long been well established.[1],[2] Engaging in regular exercise has been proven to reduce the risk of CVD with a dose-response relationship.[3] Despite its beneficial effects, exercise can occasionally trigger major adverse cardiovascular events in predisposed individuals. The residual risk of acute cardiovascular events remains during and shorty after physical exertion, and its severity is correlated with the intensity of exercise, as well as the previous physical condition.[4] Especially, vigorous physical activity might be paradoxically detrimental to susceptible individuals, triggering the development of acute coronary syndromes (ACS), life-threatening arrhythmias, sudden cardiac arrest, and sudden cardiac death (SCD) in the presence of underlying CVD.[5],[6] Unexpected deaths in young athletes have raised serious concerns since the 1960s, when autopsy-based studies investigated the possible mechanisms of such events.[7],[8] Notably, the majority of these athletes experienced sudden death during or shortly after severe exertion on the athletic field, while the most common cause of death in these series was hypertrophic cardiomyopathy (HCM). In recent years, there has been an increasing interest in reducing SCD rates in athletes.[9] In 2005, the first recommendations on the eligibility criteria for sports participation were published by the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology (ESC).[10] Since then, several updates have been released, with the most recent guidelines on Sports Cardiology and Exercise being published by the ESC in 2020.[11],[12],[13]

According to the ESC relevant guidelines, athletes are defined as “individuals of young or adult age, either amateur or professional, who are engaged in regular exercise training and participate in official sports competition.”[14] Similarly, the American Heart Association (AHA) and others define a competitive athlete as an individual involved in regular (usually intense) training in organized individual or team sports, with an emphasis on competition and performance.[15],[16] Young athletes are defined as individuals ≤35 years old. Athletes are further categorized as elite, competitive, and recreational, based mainly on exercise volume. Elite athletes are considered those who exercise more than 10 h/week, competitive athletes more than 6 h/week, whereas recreational athletes are finally considered those that exercise for a minimum of 4 h/week. Exercisers differ from athletes regarding the intent and motivation of activity. In specific, exercisers are considered to be individuals who participate in sports solely with the goal to maintain health and fitness.[17] However, the above-mentioned categories may overlap, as exercisers and recreational athletes may occasionally engage in vigorous physical activity. For a more effective quantification of exercise intensity, metabolic equivalents (METs) are employed to estimate energy expenditure.[18] Physical activities of at least 6 METs are considered of vigorous intensity.[19]

Physiological changes occurring during exercises, such as increased sympathetic activity and cardiac oxygen requirements, may lead to ischemia and trigger ventricular ectopy.[20] Thus, there is an increasing risk of acute cardiovascular events in susceptible individuals with underlying cardiac disorders, which holds especially true in previously asymptomatic patients with undiagnosed diseases.[21] In this line, a tailored preparticipation screening is fundamental for the detection of underlying pathological conditions.[22] Early detection of CVD leads to a substantial reduction of exercise-related adverse events through the implementation of disease-specific interventions and individualized recommendations regarding the volume and intensity of exercise.[23] This narrative review aims to summarize the physiological impact of physical activity on cardiovascular health, discuss the pathological substrate of acute cardiovascular events and highlight the recommended prevention strategies.

  Main Causes of Exercise-Related Cardiovascular Events Top

The pathological basis of exertion-related acute cardiovascular events varies significantly with age.[20] Younger individuals (<35 years) suffer mainly from hereditary or congenital cardiovascular abnormalities, whereas in older individuals, the most common pathological finding is coronary artery disease (CAD).[24],[25] In a study analyzing the incidence of SCD in US college athletes, 1.6 deaths per 100,000 person-years were attributed to confirmed or suspected CVD.[26] SCD in young athletes may appear in a number of disorders, which are divided into two main categories, namely structural and electrical cardiac abnormalities.[27] Notably, in apparently healthy young athletes, the overall prevalence of these disorders is approximately 0.3%.[21],[28]

Among structural disorders, HCM is the most common cause of SCD in young male athletes, accounting for 39% of sudden male deaths in the United States (US) National Registry of Athletes.[29] The diagnosis of HCM is based on the presence of unexplained left ventricular (LV) hypertrophy, defined as a maximum end-diastolic wall thickness ≥15 mm, in any myocardial segment on echocardiography, cardiovascular magnetic resonance (CMR), or computed tomography imaging (or wall thickness ≥13 mm in the context of a family history of definite HCM or a positive genetic test).[30] Nevertheless, the diagnosis of HCM in athletes sometimes can be challenging. LV hypertrophy is not an exceptional finding in male athletes (the so-called athletic heart), overlapping morphologically with emerging HCM,[12] though small imaging differences may be valuable to distinguish the two conditions. Notably, athletes with HCM have an asymmetric pattern of LV hypertrophy,[30],[31] and approximately one-third of athletes may have the apical variant,[32] while athletes with physiological LV hypertrophy show a more homogeneous and symmetric distribution of wall thickness.[33] Moreover, LV end-diastolic cavity size in individuals with HCM is normal or reduced compared to athletes with physiological LV hypertrophy, where an enlarged cavity is observed.[34] Other subtle structural anomalies, such as elongation of mitral valve leaflets, anomalous insertion of papillary muscles, myocardial crypts, and recesses may also coexist among athletes with HCM.[30],[31]

Complex ventricular arrhythmias such as ventricular tachycardia and ventricular fibrillation triggered by intense physical exertion may also develop as a result of electrical instability predisposing to cardiac arrhythmias in these individuals.[35] In more detail, chaotic LV myocardial architecture, consisting of hypertrophic myocytes with bizarre shapes and multiple intracellular connections, increased intima and medial collagen matrix deposition, as well as myocardial fibrosis, are considered to be great substrates for the development of fatal arrhythmias in HCM, while intense physical exertion seems to be the triggering factor, provoking thus the phenomenon of electrical instability.[35],[36] Notably, local conduction delay or block, abnormally fractionated electrograms, and reduced bipolar voltages represent typical electrophysiological findings.[37] In contrast, in female athletes, HCM is less common (ratio males/females, 3/2), and accordingly, in some instances of exercise-related SCDs, no structural disorders are found at autopsy.[35],[38]

Nevertheless, the risk of fatal arrhythmias during exercise and sport participation differs among all individuals with HCM, and as a result, all athletes with HCM are not restricted from competitive sports. Interestingly, current literature reveals that individuals with HCM who continue participating in sports after implantable cardioverter-defibrillator (ICD) implantation do not experience an increased number of shocks during exercise.[39],[40] Thus, an option for participation might be achievable among specific athletes with HCM after careful evaluation, proper management, and patient-focused counseling.

Congenital coronary-artery abnormalities/malformations represent the second-most common autopsy finding in young athletes, accounting for approximately 17% of SCDs in the US.[41] In particular, during exercise, ectopic coronary arteries can be compressed between the aorta and pulmonary artery trunk, leading to acute myocardial ischemia.[42] In addition, valvular disease, mainly aortic stenosis and mitral valve prolapse (MVP), has also been implicated in exertion-related SCD. Valvular regurgitation and stenosis have been correlated with compensatory ventricular enlargement, hypertrophy, and dysfunction.[43] An increase in stroke volume, heart rate, as well as myocardial contractility during physical exertion might further deteriorate valvular dysfunction.[11] As a result, patients with the valvular disease are more prone to experience syncope, myocardial ischemia, atrial or ventricular arrhythmias, as well as SCD.[43] Although individuals with MVP have an overall good prognosis, in the Italian pathology registry, 7% of SCDs were attributed to “arrhythmic MVP,” with the majority being females.[44],[45]

Specific electrical and structural abnormalities may be valuable tools to identify high-risk patients. In more detail, inverted T-waves in inferior leads and ventricular extrasystoles of the right bundle branch block create an arrhythmogenic milieu, which may lead to sustained and potentially life-threatening arrhythmias among patients with MVP.[44] Furthermore, excessive stretch by the flail leaflets causes myocardial scarring, which serves as an arrhythmogenic substrate in these patients.[46]

Other disorders possibly less commonly responsible for SCDs in young athletes are dilated cardiomyopathy, Marfan's syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC) and myocarditis. The proximate cause of death in the above-mentioned conditions is ventricular arrhythmias, except for Marfan syndrome, where aortic rupture is the main cause of death.[20] Finally, atherosclerotic CAD is rarely encountered in exercise-induced SCD in young individuals, especially in those with a genetic defect in low-density lipoprotein.[20] It should be, however, emphasized that approximately 3% of young athletes depict normal cardiac structure on autopsy.[47] These deaths can be attributed to arrhythmogenic disorders such as channelopathies (i.e. long QT syndrome and Brugada syndrome), Wolff-Parkinson-White syndrome, and catecholaminergic polymorphic tachycardia.[48],[49],[50],[51],[52] Cohort studies conducted in the US and United Kingdom in athletes with SCD revealed a high rate of structurally normal hearts during the autopsy, suggesting a high prevalence of sudden arrhythmic death syndrome.[53],[54],[55]

It should be, however, emphasized that the majority of exercise-related SCDs occur in older athletes compared to their younger counterparts. In a prospective French study addressing exercise-related SCD in the general population, only 6% regarded young competitive athletes.[56] The risk of exertion-related adverse events, such as myocardial infarction (MI) and SCD, increases during strenuous exercise in “senior” athletes. However, it is inversely associated with regular exertion levels. Most important, sedentary people have an increased risk of SCD during vigorous exercise.[57] Moreover, there is a dose-response effect, with the relative risk of myocardial infarction being reduced in individuals with regular weekly physical activity.[58] From an epidemiological point of view, CAD accounts for more than 80% of SCDs in athletes older than 35.[59],[60] The proximate cause of death in the latter cases is ischemia-induced ventricular arrhythmias; however, the mechanism has not been completely elucidated.[61] Sympathetic activation leading to ischemia and arrhythmias, metabolic factors, activation of the hemostatic mechanisms, and hemodynamic changes causing destabilization and rupture of the vulnerable atheromatous plaques represent possible mechanisms underlying SCD.[62] Similar to younger athletes, a number of other disorders may be responsible for a minority of SCDs in older athletes, such as HCM, ARVC, myocarditis, valvular disease, and channelopathies, among others.[63]

Exercise-related cardiovascular complications might be the first clinical manifestation of occult CVD. Possible prodromal symptoms that exercising individuals with CVD may experience, include the following: pain or discomfort in the chest, neck, jaw, arms, or other areas, gradually-deteriorating fatigue, heartburn, gastrointestinal symptoms, excessive or unusual breathlessness, dizziness, palpitations, as well as severe headache, ankle swelling, burning or cramping sensations in the lower extremities when walking.[24],[64] It is reported that individuals who experienced exercise-triggered cardiovascular events occasionally had prodromal symptoms, which were underestimated or even ignored or downgraded by themselves or their attending physicians.[24] Consequently, it is of major importance for exercising individuals and coaches to be aware of the possible prodromal cardiac symptoms, and if such symptoms appear, exercise should be discontinued, and medical advice should be promptly sought. Despite the above-reported concerns, the overall risk of adverse cardiovascular events during and after exercise remains still quite low, especially in individuals with long-standing physical activity.[65]

  Screening for Participation in Sports Top

A number of strategies have been proposed for the prevention of exercise-related acute cardiovascular events. At present, it is well established that early detection of potentially life-threatening disorders among athletes requires a detailed risk stratification, eventually with patient-centered interventions and exercise modifications, aiming at diminishing cardiovascular morbidity and mortality.[21],[66] Preparticipation health screening recommendations have been further updated in recent years so that clinicians may help their patients to overcome the possible barriers in the context of risk discussion and motivate them to achieve their goals. In further detail, the contemporary algorithm deals with the following parameters: status of physical activity, the presence of any known cardiovascular, metabolic, or renal disease (CMRD), the presence of cardiac-related prodromal signs and symptoms, as well as the targeted exercise intensity to be achieved.[67] Nevertheless, screening methods for exercise-related cardiovascular safety for young competitive athletes (<35 years old) still remain controversial, while there is limited evidence regarding exercise recommendations in master athletes (>35 years old).[11]

So far, several international societies, such as the AHA, American College of Sports Medicine (ACSM), and ESC have proposed preparticipation survey questionnaires for health-fitness facilities to identify individuals at high risk of cardiovascular events during exercise,[20],[68] require medical assessment before entering a training program.[64] In more detail, the physical activity readiness questionnaire (PAR-Q) is widely used as a risk stratification and screening tool.[69],[70] It is estimated that 95.5% of women and 93.5% of men would ask for medical counseling before initiating an exercise program, as it was indicated by AHA/ACSM Preparticipation Questionnaire referral criteria.[70]

Similarly, the European Association of Preventive Cardiology (EAPC) recommends self-assessment by a brief questionnaire to determine if further evaluation and advice from health professionals are demanded.[71] Furthermore, evaluation of the individual likelihood of occult CVD is recommended by calculating the respective cardiovascular risk based on ESC Systematic Coronary Risk Evaluation (SCORE) risk charts, which include major risk factors of CVD, such as very high total cholesterol and low-density lipoprotein, diabetes mellitus, as well as family history of CVD.[72]

In this line, an electrocardiogram (ECG) allows to detect of occult cardiomyopathies and primary electrical disorders and may recognize subjects requiring additional testing (such as exercise testing) toward atherosclerotic CVD. Nevertheless, routine preparticipation ECG is an area of considerable debate. False-positive exercise testing results misclassify individuals as high risk, thus preventing them from physical activity and prompting further unnecessary invasive diagnostic procedures. Usually, ECG abnormalities among young athletes are attributed to increased vagal tone and specific exercise-related cardiac remodeling.[73] Although no further investigation is needed in most instances, the likelihood of abnormal cardiovascular substrate should be individually ruled out. In this context, professional societies have provided guidelines and specific criteria to avoid misinterpretation of ECG among individuals and, thus, false diagnoses.[74]

Notably, a review of randomized controlled trials of screening with exercise ECG indicated no improvement in health outcomes, although patients at high cardiovascular risk, such as those with diabetes mellitus, were included.[75] According to a relevant AHA/ACC scientific statement, screening with resting or exercise ECG testing is of unproven benefit in asymptomatic athletes or adults at low cardiovascular risk due to the high rates of false-positive results and prohibitive cost.[28],[76] Specifically, adding resting or exercise ECG to conventional risk factor assessment does not lead to improved risk stratification or decision-making in these patients. However, this recommendation contrasts with the position of ESC.[71] The European recommendation is based on an observational study, which was performed in Italy, where ECG preparticipation screening has been mandatory in athletes since 1982. Notably, this screening method led to a significant reduction in the annual incidence of sudden death among athletes 12–35 years by 89% (from 3.6 deaths to 0.4 deaths/100,000 athletes).[21] Thus, European guidelines suggest cardiac screening with family history, symptoms, physical examination, and 12-lead resting ECG as a preparticipation cardiovascular evaluation in healthy individuals aged >35 years who are about to initiate competitive sports (Class IIa).[11]

On the other hand, exercise testing seems to be a valuable tool for identifying potential cardiovascular abnormalities before starting an exercise program in the following cases: patients at high risk, such as high-risk middle-aged or older individuals, sedentary individuals with multiple risk factors for CVD, individuals who want to participate in high-intensity endurance sports, those with elevated coronary calcium (CAC) score, in those with a family history of premature CVD who wish to participate in vigorous training sessions, and most important in subjects who complain of cardiac symptoms or suffer from valvular heart disease.[77],[78] On the other hand, patients with structural and electrical disorders of the heart, such as Wolf-Parkinson-White, Brugada syndrome, and long-QT syndrome, require a detailed evaluation before engaging in any sports activity and a close follow-up by personnel with expertise in sports cardiology.[79]

Stress ECG and stress echocardiography are additional valuable tools for detecting obstructive CAD. However, exercise-related acute cardiovascular events might be provoked by nonocclusive atheromatic lesions via plenty of mechanisms, such as coronary vasospasm and plaque rapture,[58],[80] causing myocardial ischemia and life-threatening arrhythmogenesis.[5],[81] As a result, even coronary arteriography may not provide a definite diagnosis.[82] On the other hand, coronary calcification and atherosclerotic plaques are strong predictors for future cardiovascular morbidity and mortality. Coronary calcification has been associated with long-term cardiovascular events among marathoners.[83] Interestingly, cardiovascular event rates among marathon runners with CAC scores <100, 100–399, and ≥400 were 1.5, 12.0, and 21.4% (P = 0.002), respectively, after a median follow-up of 6 years. Indeed, coronary calcification (CAC score ≥100) seems to be more prevalent in athletes when compared to the controls, and more prominent in the most active, middle-aged or older athletes compared with the less active and younger athletes.[84] Furthermore, analysis of plaque morphology demonstrated fewer mixed plaques and, more often, only calcified plaques among athletes, thus revealing a milder composition of atherosclerotic plaque.[84] As a result, the assessment of atherosclerotic burden using the CAC score provides valuable information in terms of risk stratification. CAC scoring may be an option in asymptomatic athletes with a moderate atherosclerotic risk profile.[11] Moreover, according to recent data, optical coherence tomography (OCT) might be a useful imaging technique to unveil an alternative etiology of exercise-related ACS and SCD, among patients with nonobstructive CVD, also implying a tailored to the patient treatment.[85] In specific, OCT may depict plaque rupture or erosion, coronary dissection, and calcified nodule erosion among patients with nonsignificant stenotic coronary arteries who experienced exercise-triggered ACS or SCD.

  Cardiac Screening in Young Athletes and Healthy Adults before Participation in Sports Top

At present, there is little evidence to supp ort comprehensive cardiovascular screening for the prev ention of exercise-related acute cardiovascular events among young athletes. It should be, however, stressed that careful physical examination, along with personal and family medical history, remains the milestone for the identification of subjects at risk for SCD.[64],[73],[86] The role of ECG in risk stratification among young athletes is not universally supported (e.g. in the US) due to the already mentioned nonnegligible rate of false-positive results and financial reasons.[28],[71]

Similarly, current recommendations and evidence for cardiovascular screening efficacy in athletes >35 years of age are quite limited. Despite the higher prevalence of atherosclerotic CVD in this subgroup, routine screening for myocardial ischemia with exercise testing in asymptomatic adults is not recommended due to the low positive predictive value and high rates of false-positive results.[87],[88] In this context, exercise ECG testing is recommended only in symptomatic athletes or those at high risk of CAD based on the SCORE system.[71],[72] Moreover, exercise testing or cardiopulmonary exercise testing (CPET) is useful to evaluate cardiovascular performance among adults who start moderate-to-vigorous physical activity.[11] Currently, there is no evidence for incorporating routine cardiac imaging in preparticipation screening among asymptomatic individuals aged >35 years with a normal exercise stress test.[11] Individuals with symptoms suggesting myocardial ischemia, and abnormal findings on physical examination, ECG, or exercise stress test should be further investigated eventually with coronary angiography according to ESC guidelines for chronic coronary syndromes (CCS).

  Cardiac Screening in Patients with Cardiovascular Disease before Participation in Sports Top

Exercise testing, despite its lower specificity for myocardial ischemia compared to other functional tests, is the most widely available tool with the ability to provide valuable information on exercise capacity, heart rate, blood pressure response, and detection of exercise-induced arrhythmias, especially in asymptomatic and low-risk individuals.[13] According to ESC guidelines, risk stratification for exercise-induced adverse events is recommended in individuals with the established CCS before engaging in exercise.[11] In case of borderline test results, more specific imaging stress tests such as stress-echocardiography, cardiac CMR, or single-photon emission computed tomography should be performed. Moreover, patients with heart failure (HF) who wish to participate in cardiac rehabilitation training programs should undergo a comprehensive cardiological evaluation, including measurement of blood natriuretic peptides, the performance of echocardiography and maximal exercise test, preferably CPET, to assess functional capacity, exercise-induced arrhythmias or hemodynamic abnormalities.[11],[89] In the latter patients, before considering sports activities, a preliminary optimization of HF risk factor control and therapy, including device implantation, if appropriate, is recommended.[11]

A comprehensive cardiological evaluation is also required in patients with HCM who wish to engage in sports activities. Baseline preparticipation assessment includes a detailed personal and family history taking into account age, level of exercise before diagnosis, assessment of the severity of the HCM phenotype, and the presence of conventional risk factors for SCD. In this context, 12-lead resting ECG or even preferably 48-h ECG, echocardiography, CMR imaging, and exercise testing or CPET are extremely helpful for risk stratification.[11]

Finally, precise recommendations for exercise screening and participation in sports for patients with HF with preserved or reduced ejection fraction, valvular disease, ACS, heart transplantation, arrhythmogenic or dilated cardiomyopathy, myocarditis, pericarditis, cardiac arrhythmias, channelopathies as well as adult congenital heart disease have also been reported in the 2020 ESC Guidelines on Sports Cardiology and Exercise.[11],[90]

Regarding exercise intensity, it is well established that vigorous physical activity increases the risk of acute cardiovascular events and among patients with known or occult CVD, when compared to mild-to-moderate-intensity training.[87] Therefore, cardiovascular screening restricts high-risk patients from rigorous activities. Nevertheless, these patients should be encouraged to participate in moderate training programs, to prevent obesity and atherosclerosis, with the final goal to reduce the individual future cardiac risk.[64]

According to ESC, individuals who are physically active and at low or moderate risk, based on SCORE charts, are allowed to participate in all exercise training programs without restrictions, including competitive sports.[90] Nevertheless, individuals following a sedentary lifestyle or at high or very high CVD risk (SCORE ≥5%) are eligible to participate in low-intensity exercise without further evaluation; otherwise, they should undergo a physical examination, 12-lead resting ECG, exercise stress test and on an individual basis functional imaging test or coronary computed tomography angiography before engaging in high-intensity training sessions.[90],[91] Furthermore, patients with chronic HF should be excluded from exercise programs in case of arterial hypotension or hypertension at rest or during exercise, unstable cardiac disease, deteriorating symptoms of HF, myocardial ischemia despite therapy, or severe and suboptimally treated pulmonary disease.

  Education of Fitness Personnel and Facilities for Cardiovascular Emergencies Top

Exercise-triggered cardiovascular events and death rates might be decreased if the personnel are well instructed and training facilities are well prepared to manage cardiovascular emergencies. Professional organizations recommend that coaches and trainers involved in exercise programs should be certified in cardiopulmonary resuscitation and be instructed to handle medical emergencies.[92] Moreover, the availability of automated external defibrillators in all fitness facilities has been strongly emphasized.[93],[94],[95] In addition, health-fitness facilities should perform pre-entry screening, have written emergency policies, conduct regular emergency drills and cardiopulmonary resuscitation, as well as establish a “hotline” for immediate use in case of medical emergencies.[20]

Unfortunately, it seems that there is a significant gap between international guidelines and everyday practice. It has been reported that plenty of health clubs demonstrate low compliance with national standards, thus being unprepared for cardiovascular complications.[96] In particular, failures in pre-entry cardiac screening procedures and in emergency response drills, as well as the absence of written emergency response plans and automated external defibrillators, have been detected. Therefore, healthcare facilities should offer educational seminars to their staff regarding the management of cardiac emergencies and dispose of a specified plan in such cases, along with adequate resuscitation equipment.

  Prudence of Exercise Top

The abrupt and intense physical effort seems to increase the risk of cardiac ischemia and SCD, while sudden cessation of physical activity tends to decrease central blood volume and arterial pressure.[97],[98] Thus, exercising individuals, and especially patients with established CVD, are advised to perform at least 5 min each of warm-up and cool-down in their training sessions. Furthermore, vigorous exercise in extremely cold temperatures, such as snow shoveling, has been strongly associated with a higher risk of acute cardiovascular events.[99] In contrast, individuals exercising in hot and humid environments depict high heart rates as a response to the increased thermal load, which in turn increases myocardial oxygen demands.[100] Accordingly, physically inactive individuals and patients with established CVD should be advised against participation in vigorous fitness programs in either extremely cold or hot environmental conditions.[20] Moreover, high altitude reduces oxygen availability, activates the sympathetic system, and increases cardiorespiratory demands.[101],[102],[103] Therefore, individuals exercising at an altitude above 1500 m should be aware of their exercise intensity goals, following a more prudent training policy. In summary, patients with established CVD that wish to participate in competitive sports should seek medical counseling by high-experienced physicians and specialists in sports cardiology based on AHA/ACC eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities.[73],[101],[104]

Physically inactive individuals with or without CVD are encouraged to participate regularly in training fitness programs but to gradually achieve their exercise target goal. Considering that less active individuals are at higher risk for exercise-triggered cardiovascular events, beginners should exercise slowly and then increase gradually exercise intensity and duration, if tolerated, to avoid cardiac fatalities.[105] Furthermore, previously inactive patients with or without CVD should avoid vigorous physical activity, such as racquet sport and snow removal.[106],[107] Finally, cardiac rehabilitation centers, where physicians work in partnership with their patients, offer behavioral health modification, adherence to medical treatment as well as structured and supervised training facilities, thus promoting cardiovascular health. Therefore, patients are highly encouraged to participate in the available certified programs.[108]

  Adherence to Exercise Top

Healthy lifestyles and behavioral modification are of major importance not only for the prevention but also for the management of CVD. Adherence to regular exercise significantly improves recurrent cardiovascular events, as well as complications following an ACS. Interestingly, patients with a history of recent ACS, who report non-adherence to exercise, diet, and persistent tobacco use, seem to have a 3.8-fold increased risk of MI, stroke, or death compared to those that comply with the behavioral advice.[109] Despite the strong recommendations of international guidelines, a large majority of patients with CVD follow an unhealthy lifestyle, which prevents them from achieving the previously-reported target goals for secondary prevention after a cardiovascular event.[110] Adherence to exercise may lead to a reduction in all major events by 50%, 6 months after an ACS. Therefore, initiating and maintaining a physically active lifestyle, and especially adherence to the long-term exercise training programs, among patients with CVD and/or comorbid conditions, remains a real challenge for both physicians and patients.[111]

In specific, exercise adherence seems to decrease substantially during these patients' long-term follow-up.[112] Lack of compliance is mainly attributed to several factors, such as disease-associated limitations, multiple comorbidities, and absence of motivation. According to recent data, patients after an ACS are more likely to drop out of physical activity schedule, usually within 6 months after hospital discharge,[113] while older age,[114] female sex,[115] and high body mass index (BMI),[110] have been strongly correlated to physical inactivity. Interestingly, 38% of patients after an ACS fails to maintain adequate physical activity over time.[116] Thus, clinicians should pay additional attention and optimize their efforts to patients who are less willing to change their behavioral lifestyles, such as the elderly, women, and those with obesity, as well as encourage them to participate in structured exercise training intervention programs, to achieve an adequate level of cardiorespiratory fitness.

Although some authors support that the use of aspirin and/or b-blocker may be beneficial for patients at high risk of CVD before initiating competitive exercise,[117],[118] there is no strong evidence that these medications prevent exercise-triggered acute cardiovascular events. Therefore, due to scant data availability, prophylactic use of the latter medications is not routinely recommended before vigorous physical activity or sports participation, while proper discussion and shared decision-making between clinicians and patients are highly encouraged.[64]

At present, it is speculated that “the more exercise training is always, the better,”[77] while marathon running may offer immunity to CVD.[119] Half and full marathon races, as well as triathlon events, have gained plenty of popularity, and number of athletes practicing these sports increased rapidly during the past decades. Nevertheless, reports of marathon runners dying during races are coming to the public's attention due to known or occult CVD, in combination with extreme physical and environmental conditions such as cold, heat, and humidity.[120] It seems that inadequate preparation or poor training is strongly correlated with exercise-related fatalities.[121] Moreover, sprinting during the final miles has been associated with a greater risk of acute cardiovascular events,[62] and as a result, competitors at high risk or cardiac events should be advised to maintain stability in their running through the whole race. Therefore, personalized counseling and appropriate management are of great importance.

  Novel Prevention Strategies Top

It is quite challenging for physicians to implement guidelines into everyday clinical practice based on patients' cardiovascular profiles and needs. As far as exercise training programs are concerned, exercise prescription for an individual is even more tricky since international recommendations should combine a patient's cardiovascular history along with concomitant medications and the presence of comorbidities. Indeed, remarkable technological progress in the field of personalized medicine provides novel tools who may also apply in the context of Sports Cardiology.

The EAPC exercise prescription in everyday practice and rehabilitative training (EXPERT) tool is an interactive, digital training and support system, which aims to help not exclusively cardiovascular rehabilitation or sports medicine specialists but also family physicians, cardiologists, and other medical specialties, to prescribe clinically effective and medically safe exercise training programs among patients with CVD.[122] This website application offers health-care professionals the chance to choose and implement the most optimal and effective exercise training program for each patient. However, a structured setting, along with skilled and licensed supervisors, should be guaranteed to reach the desired cardiorespiratory outcomes, diminishing the risk of cardiac-related adverse events.

In further detail, the “EXPERT” is a 4-step process. Initially, patient characteristics, based on clinical examination and laboratory findings, should be entered as parameters into the online platform. The next step is to select the presence of CVD, as well as risk factors for CVD when present. Specific contaminant medications that might interfere with the exercise training procedure, such as b-blockers, statins, insulin administration, and other anti-diabetic agents, are taken into account. Furthermore, exercise-related adverse cardiovascular events, such as myocardial ischemia, cardiac arrhythmias, or the presence of ICD, are also addressed. Finally, the “EXPERT” tool will generate the most-appropriate exercise training program for each patient, discouraging certain types of exercise and providing individualized safety advice.[122] Interestingly, personalized recommendations regarding exercise training intensity, frequency duration, type, session, as well as additional exercise training modalities will be provided. Thus, guided, detailed, and comprehensive exercise prescription is easily accessible to physicians and patients, thus achieving better treatment and outcomes.

  How Can the Guidelines Guide Us? Top

Both improving exercise capacity and optimizing the safety of cardiorespiratory training programs play a major role in promoting cardiovascular health. Thus, international organizations, professional societies, health-care professionals, and policy makers show an upgrowing interest in exercise-derived cardiovascular benefits, providing systemic recommendations as well as prevention strategies, as presented in [Figure 1]. According to the 2019 ACC/AHA Guideline on the Primary Prevention of CVD, in general, healthy individuals should undergo at least 150 min/week of accumulated moderate-intensity physical activity. Otherwise, 75 min/week of vigorous-intensity physical activity to reduce the risk of atherosclerotic CVD.[123] In agreement with the previous recommendations, ESC suggests that additional benefit is achieved by doubling the previous exercise duration, with multiple sessions of exercise carried out throughout the week.[11],[72] In case that individuals are unable to comply with the previous recommendation, participation in moderate or vigorous-intensity physical activity, even below the target goal, might also be beneficial for the cardiovascular system.
Figure 1: Prevention strategies for exercise-related acute cardiovascular events

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Furthermore, it is of major importance that health-care professionals provide patient-focused counseling to help them optimize their physical activity status.[123] In particular, physically active asymptomatic individuals without known CMRD may continue their usual moderate or vigorous exercise and progress gradually as tolerated, while those with CMRD who have been medically evaluated the previous year, may continue a moderate-intensity exercise program.[64],[124] On the other hand, physically inactive individuals without known CMRD may begin mild-to-moderate-intensity exercise without medical guidance, and if they remain asymptomatic, progress gradually in intensity, while those with known CMRD or suggestive should seek medical guidance before starting an exercise program, regardless of the intensity[18],[80],[64],[124] Although the exercise-related health benefits outweigh the potential cardiovascular risks, individuals who develop signs or symptoms during exercise should immediately discontinue training sessions and seek medical care before resuming the exercise of any intensity.[124]

In addition, prescription of exercise and easy access to well-structured and fully-organized training facilities for physical activity are also recommended.[123] Exercise-based cardiac rehabilitation is recommended in all individuals with CAD to reduce cardiac mortality and rehospitalization, while participation in competitive sports is not recommended in individuals with CCS, at high risk for exercise-induced adverse events or those with residual ischemia. In addition, exercise-based cardiac rehabilitation is recommended in all stable individuals with HF to improve exercise capacity and quality of life and to reduce the rate of hospital readmission.[11] As far as HCM is concerned, participation in high-intensity exercise (including recreational and competitive sports) is not recommended in high-risk individuals.[11] Finally, as already mentioned, individuals with congenital or structural cardiovascular abnormalities should ask for specialized counseling by highly experienced physicians and avoid engagement in highly competitive or vigorous endurance training sessions in the absence of medical guidance, whereas leisure-time or low-to-moderate-intensity physical activity might be more appropriate in this setting.[77]

  Conclusions Top

A healthy lifestyle, and especially exercise training, throughout life, is the cornerstone for the prevention of atherosclerotic CVD. Notably, exercise training enhances functional capacity, muscle strength and endurance, quality of life, and cardiac-related biomarkers, thus improving significantly cardiovascular risk and survival rates. According to evidence-based recommendations for the prevention of CVD, a comprehensive and more personalized approach should be applied, taking into account the individual behavioral habits and estimated risk of future cardiovascular events. Detailed strategies should be catholically applied both in young or older athletes, patients with established CVD or risk factors for CVD in order to prevent exercise-triggered cardiovascular events. Participation in structured programs for therapy optimization and adherence, and risk factor modification, including exercise training and smoke cessation, improves the quality of care and is highly recommended to patients with established CVD or risk factors for CVD. Health-care providers should not overestimate the risks of exercise since the exercise-related cardiovascular benefit outweighs significantly any potential harms. The rule of “Primum Non-Nocere” should always be applied when an exercise program is advised.

Ethical Statement

The ethical statement is not applicable for this article.

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Conflicts of interest

There are no conflicts of interest.

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