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The European Society of Cardiology (ESC) released its first guidelines for sports and physical activity in all types of heart disease, mirroring in major respects the U.S. guidelines but also drilling in deeper on specific conditions.

Overall, the guidelines, published and discussed at the , agreed with U.S. recommendations for 150 minutes per week of moderate physical activity or 75 minutes of vigorous intensity activity as the goal for healthy adults.

The guidelines fill in the gaps on "how to evaluate patients with a broad spectrum of cardiovascular conditions, what kind of testing is appropriate in that single disease, how to read the results, and eventually how to advise the type, the sport, and modality to participate," said task force chairperson Antonio Pelliccia, MD, of the Institute of Sport Medicine and Science in Rome, at an ESC conference session.

For example, people with type 2 diabetes got a class Ia recommendation for resistance training at least three times a week along with moderate to vigorous aerobic exercise most days of the week. Those with hypertension that is uncontrolled, high-risk, or that has caused target organ damage got a class IIIc recommendation against high-intensity exercise.

"In many respects it echoes what the U.S. statement said several years ago and updates it on a few fronts," commented Barry Franklin, PhD, of William Beaumont Hospital in Royal Oak, Michigan, who has been on a number of American Heart Association guideline committees addressing physical activity.

American guidelines on by people with cardiovascular abnormalities date back to 2015, with general physical activity guidelines for the general public released in 2018.

The new European guideline agrees with the U.S. versions that a stress test isn't necessary for everyone with heart disease who starts an exercise program, he noted. Low-risk patients with coronary artery disease -- those with no ongoing ischemia or ST-segment elevation and who show rhythm regularity and a good ejection fraction -- can usually safely participate in competitive and endurance sports without any pre-participation cardiovascular assessment.

That assessment could be a stress test, but "there's also room now for functional imaging or imaging with CT scan," Pelliccia noted.

Cardiomyopathy patients, depending on the type and degree, need testing before starting an exercise program or sports but often can participate in even vigorous activity.

On the other hand, said Franklin, the new statement "really further differentiates" the fact that coronary disease patients with ejection fraction under 35% or evidence of ongoing ischemia shouldn't be doing high intensity or vigorous physical activity.

Another difference is that the ESC guideline more explicitly defines recommendations for subsets of cardiac patients, he said, pointing out that moderate-to-vigorous activity is usually safe for those with heart failure and in fact may improve their prognosis.

Arrhythmia patients need to be evaluated before participation, with a graded exercise stress test at the very least, to determine if the arrhythmia is exacerbated by moderate to vigorous activity. More specific recommendations were given for drug and ablation strategies as well.

For valvular disease, the take-home-message was that at least some exercise is recommended across the board, with no restrictions on intensity for those with mild disease but no intense exercise with severe stenosis.

People with myocarditis or pericarditis should refrain from vigorous activity and competitive sports while inflammation remains, regardless of age or extent of left ventricular systolic dysfunction, likely for 3 to 6 months.

The guidelines did not address cardiac inflammation due to COVID-19 or the virus more generally. Franklin suggested that, in the absence of any good evidence, it's reasonable to start slowly back into a walking program for those without ongoing symptoms or chest pain.

Martin Halle, MD, of the Technical University of Munich and a co-author on the guidelines, cautioned that, for the guidelines overall, "the level of evidence is rather low, so it is very much the personal perspective, the experience, of the experts that actually made us come to our conclusion on recommendations."

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