Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities

Authors, Journal, Affiliations, Type, DOI

• Authors: Jonathan H. Kim (Chair), Aaron L. Baggish, Benjamin D. Levine (Vice Chairs), Michael J. Ackerman, Sharlene M. Day, Elizabeth H. Dineen, J. Sawalla Guseh II, Andre La Gerche, Rachel Lampert, Matthew W. Martinez, Michael Papadakis, Dermot M. Phelan, Keri M. Shafer; on behalf of AHA and ACC. 49 international experts in total.
• Journal: Circulation 2025;151:e716–e761
• Type: AHA/ACC Scientific Statement (5th US-based expert consensus; replaces 2015 statement)
• DOI: https://doi.org/10.1161/CIR.0000000000001297
• Published: March 18, 2025

Overview

This is the fifth US-based AHA/ACC expert consensus on competitive sports participation in athletes with cardiovascular disease (CVD), the first since 2015. The document marks a fundamental paradigm shift: away from paternalistic, universal sport restriction toward shared decision-making (SDM) as the foundational clinical principle for all athletes with CVD. Organized into 11 sections covering sports classification, preparticipation evaluation, ethics, cardiomyopathies, myocarditis/pericarditis/valvular disease, congenital heart disease, aortopathy, arrhythmias, channelopathies, masters athletes, and additional conditions. Key supporting data include the LIVE-HCM trial (no increased events with vigorous exercise in HCM), multicenter SDM outcome registries showing low breakthrough event rates in athletes with genetic heart conditions, and emerging outcome data on competitive sports safety in LQTS/CPVT under expert supervision.

Keywords

Athletes, cardiovascular abnormalities, sports, sudden cardiac arrest, shared decision-making, sports cardiology, AHA Scientific Statements

Key Takeaways

Section I: Sports Classifications

• Sports classification updated to a continuum of endurance and strength demands — discrete risk bins from previous iterations removed, reflecting the SDM philosophy of individualized risk assessment rather than categorical restriction.
• Sports also classified by bodily collision/impact risk relevant to athletes on anticoagulation (Table 3): low, intermediate (SDM required), and high risk (risks likely outweigh benefits for anticoagulated athletes).
• Full anticoagulation athletes should not participate in high-collision sports; aspirin monotherapy athletes can participate in all sports.

Section II: Preparticipation Cardiac Evaluation

• History and physical (H&P): Has low sensitivity (10–20%) but identifies symptomatic individuals and family history suggestive of inherited CVD. Newer digital tools may improve sensitivity.
• 12-lead ECG: Increases sensitivity to 94% for detecting potentially fatal cardiac conditions. Reasonable to include if adequate downstream expertise and resources are available (including sports cardiology consultation). Contemporary athletic ECG interpretation criteria substantially improved sensitivity/specificity but carry racial disparities — higher false-positive rates in Black athletes remain a significant equity gap.
• Cardiac imaging, exercise testing, ambulatory rhythm monitoring, genetic testing: Insufficient data to recommend as primary screening in asymptomatic athletes.
• Emergency Action Plan (EAP): All sporting venues must have a written EAP including trained CPR + AED access + coordinated transport. Annual practice drills essential.

Section III: Ethical Aspects and SDM

• SDM is an ethical imperative — the historical paternalistic model ("athletes cannot make rational decisions") is ethically unjustified and clinically unsupported.
• Practical SDM: (1) confirm diagnosis + risk stratification + guideline-directed therapy; (2) educate athlete on risks/benefits/uncertainties; (3) elicit athlete's values, risk tolerance, goals; (4) engage stakeholders; (5) implement + longitudinal surveillance.
• Athletes <18 years: parents/guardians must be involved with informed consent.
• Legal framework: No established precedent for SDM liability in sports. Knapp vs. Northwestern (1996) upheld team physician discretion for exclusion; does not address SDM's legal protections.
• SDM documentation is essential: document process, athlete's understanding, and outcome.

Section IV: Cardiomyopathies

• General: Uniform restriction should NOT be applied. SDM, risk stratification, guideline-directed therapy, and longitudinal reassessment are central.
• ICD: Should NOT be implanted solely for the purpose of enabling competitive sports participation.
• HCM:
  • Genotype+/phenotype-: can participate in competitive sports.
  • Clinical HCM: reasonable to consider competitive sports after comprehensive expert assessment with SDM discussing risks (including SCD). Supported by LIVE-HCM data (no increased malignant VA in HCM with vigorous exercise vs. less active individuals).
• DCM:
  • Genotype+/phenotype-: reasonable to participate.
  • Clinical DCM: reasonable to consider after expert SDM. Effect of vigorous exercise on disease progression and SCA risk is unknown.
  • LMNA variants: close surveillance warranted; preliminary evidence suggests higher cumulative exercise → lower LVEF in LMNA-DCM.
  • EF <40% or symptomatic DCM: higher risk — athlete should be aware.
• Arrhythmogenic Cardiomyopathy (ACM):
  • Genotype+/phenotype- (any genotype): reasonable to consider with SDM; close surveillance (imaging every 6–12 months) to detect phenotypic conversion, especially for PKP2 variants.
  • PKP2 ACM (clinical diagnosis): Risks of VA, structural progression, and SCD with endurance/high-intensity sport likely outweigh benefits. This is the most restrictive recommendation for ACM.
  • Non-PKP2 ACM (clinical diagnosis): Can consider competitive sports with SDM; evidence for increased SCA or disease acceleration not established for non-PKP2 genotypes.
• Left Ventricular Hypertrabeculation (LVHT): No longer a distinct cardiomyopathy. Asymptomatic athletes without cardiomyopathic features can participate. Apply DCM or HCM considerations if LVHT coexists with DCM or HCM phenotype.

Section V: Myocarditis, Pericarditis, Valvular Heart Disease, and Acquired Conditions

• Myocarditis:
  • CMR recommended for evaluation.
  • Preserved LV function: Return to sport can be considered at 4–6 weeks after resolution of inflammation (T2 signal/biomarkers) and absence of arrhythmias — shorter than the previous empirical 3-month restriction.
  • Reduced LV function: Return to sport reasonable after ≥3 months with LV recovery + inflammation resolution + no arrhythmias.
  • Persistent LGE (non-T2): Reasonable to continue sports if normal LV + no arrhythmias, with longitudinal surveillance.
  • Should not participate until active inflammation resolved (T2 or elevated troponin), regardless of LV function.
• SARS-CoV-2/COVID-19: No cardiac testing if non-cardiopulmonary symptoms. Cardiopulmonary symptoms after acute COVID: cardiac evaluation to exclude myocarditis. Long COVID with cardiopulmonary symptoms: cardiac evaluation + supervised exercise training as part of recovery.
• SARS-CoV-2 vaccination: Post-vaccination flu-like symptoms: no cardiac evaluation needed. Acute cardiopulmonary symptoms within 1 week of vaccination: evaluate for vaccine-associated myocarditis.
• Pericarditis: No sport during active phase. Return when asymptomatic + biomarkers normalized; gradual resumption. Chronic recurrent pericarditis/constriction: risks may outweigh benefits.
• Valvular Heart Disease:
  • Mild AS/AR/MR/MS: can participate.
  • Moderate AS: exercise testing to sport-specific level recommended; SDM for participation.
  • Severe AS: risks likely outweigh benefits (except lower-intensity sports). Intervention should be considered.
  • Severe MR/AR: reasonable if preserved LV + no PH + normal exercise tolerance + no exercise-induced VA.
  • Bioprosthetic valves + normal LV function: reasonable post-sternal healing.
  • Mechanical valves (requiring indefinite anticoagulation): risks likely outweigh benefits in collision/impact sports.
• Mitral Valve Prolapse (MVP):
  • Asymptomatic without high-risk features: no restriction.
  • High-risk MVP features: exercise testing + ambulatory monitoring + CMR.
  • Arrhythmic MVP: expert evaluation + arrhythmia suppression required; SDM for sports return.
• Infiltrative cardiomyopathies (amyloidosis, Anderson-Fabry, sarcoidosis, hemochromatosis):
  • Gene+/phenotype-: can participate.
  • Clinical expression + high-risk features (HF symptoms, VA, reduced LV function): risks likely outweigh benefits.
  • Clinically stable on treatment with normal LV function: can consider with SDM.

Section VI: Congenital Heart Disease

• SCA/SCD in CHD is uncommon but data are limited. SDM required for all athletes with CHD.
• Left–right shunts (small): Can participate in all sports after evaluation.
• Large shunts: Intervention likely indicated; reasonable to consider sports pre- and post-intervention with SDM.
• RVOT/LVOT obstruction: Severe obstruction requires intervention before competitive sports.
• Tetralogy of Fallot: Risk stratification (imaging, exercise testing, ambulatory monitoring) required before competitive sports.
• Anomalous Aortic Origin of Left Coronary Artery (AAOCA) — interarterial: Surgical repair required before competitive sports. Assessment for myocardial fibrosis at diagnosis.
• AAOCA right (interarterial): Reasonable if no symptoms/ischemia; surgical repair if ischemia present.
• Myocardial bridging: Asymptomatic: no restriction. Symptomatic: ischemia assessment; treat if ischemia present before sport.

Section VII: Aortopathy, BAV, and SCAD

• BAV + normal aortic dimensions: Can participate.
• BAV + mild-moderate dilation (40–44 mm): Reasonable with SDM if no additional dissection risk factors (family history, rapid growth ≥3mm/year, HTAD features).
• BAV + ≥45 mm: Risks likely outweigh benefits; select cases with SDM and expert consultation.
• HTAD (Marfan, Loeys-Dietz, vascular Ehlers-Danlos, gene-positive): Higher risk at smaller diameters. High-intensity strength sports risks likely outweigh benefits even with normal aortic dimensions. Risks outweigh benefits with aortic dilation.
• Unexplained aortic dilation ≤42 mm: Generally can participate.
• Unexplained 43–44 mm: SDM with experts; longitudinal surveillance.
• Unexplained ≥45 mm: Risks may outweigh benefits; select cases with SDM.
• Previous aortic dissection: Cannot participate in competitive sports.
• SCAD: Risks likely outweigh benefits for competitive sports post-SCAD. Cardiac rehabilitation strongly recommended after SCAD.

Section VIII: Arrhythmias, ICDs, and ECG Abnormalities

• Incidentally detected low-risk arrhythmias (isolated PVCs, AF, SVT): Can continue sports during evaluation.
• Potentially high-risk arrhythmias (complex PVCs, VT, exertional syncope): Risks likely outweigh benefits during evaluation.
• Benign PVCs: Can participate. After ablation: return after vascular access site healing.
• High-risk VA: SDM based on underlying diagnosis + treatment efficacy + longitudinal monitoring.
• Malignant VT/VF with reversible cause: Reasonable to return after treatment confirmed successful.
• SCA survivor: Reasonable with SDM considering underlying diagnosis, treatment, and confirmed rhythm stability on maximum-effort sport-specific testing + extended ambulatory monitoring.
• ICD:
  • Competitive sports reasonable for primary or secondary prevention ICD patients with SDM.
  • Post-new ICD implant: restrict for 4–8 weeks (or 2 weeks for generator replacement).
  • Collision/impact sports with ICD: can consider with SDM addressing device damage/malfunction risk.
  • ICD should NOT be implanted solely to enable competitive sports participation — ~5%/year inappropriate shock risk and ~4%/year ICD-related complication risk.
• AF/SVT: Not SCA risks. Can continue sports during evaluation. Ablation first-line for symptomatic. Anticoagulation for AF: risks of bleeding likely outweigh benefits in collision sports.
• WPW: Symptomatic WPW: electrophysiologist consultation required. Asymptomatic WPW: no restriction during evaluation; SDM regarding invasive vs. noninvasive risk stratification.
• Exertional syncope: Reasonable after complete evaluation without concerning findings; implantable loop recorder reasonable if clinical uncertainty remains.
• Non-exertional neurally mediated syncope: Return without further evaluation.
• Bradycardia and pacemakers: Sinus bradycardia/first-degree AV block/Wenckebach = normal. Symptomatic bradycardia: evaluation before sport. Pacemaker-dependent athletes + collision sports: SDM.

Section IX: Cardiac Channelopathies

• ICD for the sole purpose of competitive sports participation should not be performed in channelopathy patients.
• LQTS:
  • Concealed variant-positive LQTS (gene+, QTc <460 ms): Reasonable to participate. Largest cohort (n=494) reported zero deaths, 0.3 events/100 patient-years.
  • Phenotypic LQTS (QTc ≥460/470/480 ms, asymptomatic or previously symptomatic): Reasonable with SDM under expert supervision + non-selective beta-blockers (nadolol/propranolol) + EAP with AED. Largest cohort showed zero deaths and 1.16 events/100 athlete-years. Escalation to mexiletine (LQT3), LCSD, or ICD for higher-risk cases.
  • LQT1 swimmers/divers: Can consider with precautions: supervision by CPR-trained person, pool preferred over open water, AED access.
  • Clinical stability (no breakthrough arrhythmias) required for ≥3 months before return if symptomatic or requiring therapy escalation.
• CPVT:
  • Gene+/phenotype- (no exercise-induced ectopy on exercise stress testing): Reasonable to participate; discuss prophylactic CPVT-directed therapy.
  • Asymptomatic CPVT with exercise-induced ectopy: Can consider after optimization of therapies (BB + flecainide) and normalization of stress test.
  • Previously symptomatic CPVT: Requires combination BB + flecainide ± LCSD with normalized stress test before competitive sports. Adequate suppression = ideally no ectopy; bigeminal PVCs may be acceptable; couplets or NSVT require continued therapy intensification.
  • Serial burst exercise stress testing 1–2×/year for longitudinal monitoring.
• Brugada Syndrome: No data support competitive sports restrictions for BrS. Athletes should avoid known triggers: heat exhaustion, exercise during febrile illness, dehydration. Hydration during exercise should be prioritized.

Section X: Masters Athletes (≥35 years)

• Coronary Artery Disease:
  • Low-risk: No routine testing including CAC; guideline-based lifestyle counseling.
  • Intermediate/high-risk: Guideline-based medical therapy + SDM for further risk stratification (CAC, maximal exercise testing, coronary CT angiography).
  • Stable CAD: Benefits likely outweigh risks if normal LV + no ischemia + no arrhythmias + no wall motion abnormalities on maximal exercise testing.
  • Post-ACS: Structured cardiac rehabilitation first; return at 3–6 months if reassuring stress test criteria met.
  • CAC is common in masters endurance athletes; high cardiorespiratory fitness reduces risk associated with equivalent CAC scores.
• Atrial Fibrillation: Masters endurance athletes have higher relative AF risk. Can participate as symptom-tolerated during evaluation. PVI reasonable for symptomatic AF; return 7–14 days post-PVI (access site healing), acknowledging possible AF recurrence risk with vigorous exercise for ~2–3 months post-PVI.
• Myocardial Fibrosis (RV insertion points): Incidental finding in masters athletes; not clinically significant pathology; can continue sports.
• Aortic Dilation/Aneurysm:
  • Endurance sports reasonable if unexplained dilation <45 mm.
  • Endurance sports can consider with SDM for 45–49 mm; strength sports with intensity alterations.
  • ≥50 mm: should not participate; surgical consultation.
  • Post-surgical repair: can consider with SDM after complete sternal healing.
• Antithrombotic therapy: Antiplatelet monotherapy: all sports. Full anticoagulation: risks outweigh benefits for collision/impact sports. DAPT: SDM for collision sports.

Section XI: Additional Conditions

• Hypertension: Any stage: can participate (except hypertensive emergency). Lifestyle modification and antihypertensive medication if persistent. Cross-reference drug lists with sport governing body banned substances.
• Commotio Cordis: Education of all stakeholders. Cardiac evaluation in survivors to exclude underlying disease. Survivors can resume sports with SDM. Soft/approved projectiles and chest protectors reduce risk.
• Pulmonary Embolism: Therapeutic anticoagulation per guidelines. Risks of collision sports while anticoagulated likely outweigh benefits. Longitudinal surveillance for CTEPD/pulmonary hypertension after PE.
• Performance-Enhancing Drugs/Supplements: Education and counseling mandatory. Cardiovascular toxicity of anabolic steroids may include SCA risk.
• High Altitude (>2500 m): Generally well-tolerated; pulmonary arterial hypertension and right-to-left shunts = elevated risk.
• Scuba/Free Diving: PFO not a contraindication to recreational diving; routine PFO screening not indicated. Cardiac risk assessment for those with established CVD.
• Pregnancy: Preconception consultation with maternal-fetal medicine. Reasonable to continue sports if no pregnancy-related contraindications. Avoid collision/impact sports and high-risk environments (hypoxia, extreme heat). Individualized postpartum return-to-sport guidance needed.

Limitations of the Document

• Observational, registry-based data underpin many key recommendations — randomized trials in athletic populations are largely absent.
• Long-term safety data for continued competitive sports participation in athletes with genetic cardiomyopathies (HCM, DCM, ACM) are not yet available.
• Prospective multicenter data are ongoing (Outcomes Registry for Cardiac Conditions in Athletes — ORCCA) but not yet mature.
• Many recommendations rely on SDM, introducing inherent variability in clinical application.
• Racial disparities in ECG screening (higher false-positive rates in Black athletes) are acknowledged but not yet resolved — new criteria are needed.
• Sports classification cutoffs are approximations; individual athlete variation within any sport is substantial.
• Legal framework for SDM in sports remains untested — no established precedent for clinician liability or protection.
• Data for masters athletes with CHD or during pregnancy are particularly sparse.

Key Concepts Mentioned

• concepts/Sports-Cardiology-SDM — foundational framework for all clinical decisions in this statement
• concepts/Exercise-in-HCM — HCM no-restriction paradigm reinforced with LIVE-HCM data
• concepts/Exercise-Restriction-in-ARVC — PKP2-specific restriction vs. SDM for non-PKP2 ACM
• concepts/Sudden-Cardiac-Death — updated epidemiology; autopsy-negative sudden unexplained death most common in <35 years
• concepts/Late-Gadolinium-Enhancement — central to myocarditis return-to-sport and MVP risk stratification
• concepts/Left-Cardiac-Sympathetic-Denervation — adjunct therapy for LQTS and CPVT in athletes
• concepts/Cascade-Family-Screening — genotype+/phenotype- athletes can generally participate
• concepts/DAPT-Strategies — anticoagulation and collision sport guidance in Section I/X/XI

Key Entities Mentioned

• entities/HCM — no universal restriction; LIVE-HCM supports SDM approach
• entities/DCM — reasonable to consider competitive sports; LMNA warrants close surveillance
• entities/ARVC — PKP2 restriction maintained; non-PKP2 ACM can consider sports with SDM
• entities/Long-QT-Syndrome — competitive sports reasonable under expert supervision; zero deaths in largest cohort
• entities/CPVT — competitive sports can be considered with stable disease and therapy optimization
• entities/Brugada-Syndrome — no sports restrictions; trigger avoidance recommended
• entities/Atrial-Fibrillation — athletes with AF; masters athlete AF management
• entities/Pulmonary-Embolism — anticoagulation and collision sport guidance
• entities/Hypertension — can participate in all stages except hypertensive emergency

Wiki Pages Updated

• wiki/sources/competitive-sports-aha-2025.md — created (this file)
• wiki/sourceindex.md — source entry added
• wiki/wikiindex.md — new concept page entry added
• wiki/concepts/Sports-Cardiology-SDM.md — created
• wiki/concepts/Exercise-in-HCM.md — updated with AHA 2025 SDM data
• wiki/concepts/Exercise-Restriction-in-ARVC.md — updated with PKP2 vs. non-PKP2 distinction
• wiki/entities/HCM.md — sports participation section updated
• wiki/entities/DCM.md — sports participation section updated
• wiki/entities/ARVC.md — sports participation section updated
• wiki/entities/Long-QT-Syndrome.md — sports participation section added
• wiki/entities/CPVT.md — sports participation section updated
• wiki/entities/Brugada-Syndrome.md — sports participation section added