Guido Claessen

Background: Atrial fibrillation (AF) is a prevalent arrhythmia in endurance athletes, and many athletes report exercise as a trigger for AF episodes. We aimed to investigate the association between exercise sessions and arrhythmia episodes in endurance athletes with paroxysmal AF. Methods: In endurance athletes diagnosed with paroxysmal AF, we continuously monitored arrhythmia episodes using insertable cardiac monitors and report event rates per 24 hours and temporal relation of arrhythmias with exercise sessions. Sports watches and chest straps were used for exercise monitoring. Exercise with a heart rate of 76% to 84% and ≥ 85% of the individual maximum heart rate was classified as high and very high intensity, respectively. Results: Forty‐seven athletes (age 57±10, range 33–75 years, 3 women) were monitored with insertable cardiac monitors for a total of 55 994 hours (median 1008 [840–1344] equaling 42 days [35–56]) and performed a total of 1722 hours of exercise, of which 592 hours at high or very high intensity. Thirty‐one athletes (66%) had a total of 1445 (median 17 [3–33]) AF episodes during monitoring. Thirteen athletes (27%) had AF during exercise of whom 2 had AF during high‐intensity sessions. The event rate of AF was not higher during (0.34 per 24 hours [95% CI, 0.13–0.65]) or subsequently following an exercise session (0.37 [95% CI, 0.10–0.71]), compared with unrelated to exercise (>3 hours after, 0.61 [95% CI, 0.26–1.13]). There were no episodes of exercise‐related ventricular tachycardia. Conclusions: In this study on endurance athletes with paroxysmal AF, the rate of AF episodes was not increased during or subsequently following exercise sessions. Registration: URL: Study Details: NCT04991337. Effects of Detraining in Endurance Athletes With Atrial Fibrillation. ClinicalTrials.gov (NEXAF Detraining).

Regular physical activity offers numerous benefits to children's health and well-being and is essential for reducing cardiovascular risk in children with cardiovascular disease. Despite increasing evidence supporting its benefits, many young patients remain insufficiently active because of concerns regarding exercise related risks, limited expertise. This clinical consensus statement provides practical guidance for the prescription of exercise and physical activity in children and adolescents aged 6 to 17 years with cardiovascular disease. The document aims to bridge the gap between evidence supporting the benefits of physical activity and its implementation in daily clinical practice, promoting safe participation in sport and exercise across a broad spectrum of cardiovascular conditions. This consensus statement outlines an individualised, patient-centred approach to exercise prescription based on clinical assessment, cardiovascular risk stratification, and the FITT principle: frequency, intensity, time, and type. Specific recommendations are provided for congenital and acquired heart disease, cardiomyopathies, arrhythmias, pulmonary hypertension, cardio-oncology patients, and children with physical disabilities or syndromes. The document emphasises the importance of multidisciplinary care, periodic follow up, exercise testing when indicated, and tailored programs adapted to the child’s clinical condition, developmental stage, and personal preferences. The overarching goal is to encourage safe and enjoyable participation in physical activity, improve quality of life and functional capacity, and foster lifelong healthy behaviours in children with cardiovascular disease.

Long-term exposure to high-intensity endurance exercise induces significant physiological cardiovascular remodelling. However, recent evidence suggests that prolonged exercise in athletes, particularly those exposed to decades of intensive training, may be associated with features of cardiovascular ‘wear and tear’. These include electrical changes such as an increased risk of sinus node dysfunction and atrial fibrillation as well as structural abnormalities such as focal non-ischaemic fibrosis and coronary artery calcification, more frequently observed in middle-aged and older endurance athletes. These observations suggest that long-term high-intensity exercise may have deleterious cardiovascular effects in susceptible individuals, although the available data are primarily derived from male Caucasian athletes. While the clinical significance of these potentially maladaptive changes at the individual level remains uncertain, at a population level, high intensities and volumes of physical activity are consistently associated with reduced cardiovascular and all-cause mortality compared with sedentary behaviour, although the incremental survival benefit may plateau at very high exercise volumes. This review critically appraises the available evidence on chronic adverse cardiovascular adaptations associated with intense endurance exercise, highlighting unresolved controversies, sex- and ethnicity-related knowledge gaps, and the need to balance potential risks against the well-established survival benefits of lifelong physical activity.

Background: Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous disease characterized by exercise intolerance. Defining pathophysiologically distinct subgroups allows more personalized therapy, but efforts mainly relied on resting examinations. This study aimed to define HFpEF phenotypes based on exercise limitations using combined cardiopulmonary exercise testing with stress echocardiography. Methods: A total of 913 patients with HFpEF were recruited from 4 third‐line centers and divided into derivation (n=623) and validation cohorts (n=290). Unsupervised graph‐based clustering of 61 cardiopulmonary exercise testing with stress echocardiography variables was used to identify HFpEF exercise phenotypes. Pathophysiological characteristics, exercise capacity, and clinical outcomes were compared between phenotypes. Results: In the derivation cohort, cluster analysis identified 5 distinct HFpEF exercise phenotypes characterized by specific exercise responses: mild diastolic dysfunction (phenotype 1), impaired peripheral oxygen extraction (phenotype 2), right ventricular‐pulmonary artery uncoupling (phenotype 3), reduced left ventricular systolic reserve (phenotype 4), and chronotropic incompetence (phenotype 5). The composite outcome of all‐cause death and unplanned cardiovascular hospitalization differed significantly across phenotypes, with phenotypes 2 (hazard ratio [HR], 1.76 [95% CI, 1.07–2.91]), 4 (HR, 2.15 [95% CI, 1.27–3.65]), and 5 (HR, 2.19 [95% CI, 1.33–3.61]) showing higher rates of the primary combined outcome compared with phenotype 1. All phenotypes were replicated in the validation cohort. Conclusions: Deep phenotyping of the exercise response in patients with HFpEF revealed 5 distinct phenogroups with marked differences in pathophysiology, exercise performance, and clinical outcomes. This subclassification may support more personalized therapeutic strategies and improve risk stratification in HFpEF.

Aims: To describe exercise haemodynamics across cardiac damage stages and evaluate the incremental prognostic impact of cardiac damage stage and exercise-induced pulmonary hypertension (exPHT) in patients with symptomatic moderate aortic stenosis (AS) and asymptomatic severe AS. Methods and results: A total of 436 consecutive patients with ≥ moderate AS (74 ± 10 years, 32% women, 56% severe AS) underwent cardiopulmonary exercise testing with echocardiography. The primary endpoint was heart failure (HF) death and HF hospitalizations. Cardiac damage stage was 0 in 93 patients, 1 (LV damage) in 135, 2 (LA/mitral damage) in 135, and 3–4 (pulmonary vasculature/tricuspid or RV damage) in 73. Higher stages were associated with worse exercise capacity and haemodynamics. Over a median follow-up of 37 months, 65 patients met the primary endpoint. After adjustment for age, AS severity, and aortic valve replacement, cardiac damage stage and exPHT were independently associated with HF outcomes [HR per stage increase 1.51 (1.26–1.82); P < 0.001; exPHT HR 2.36 (1.10–5.07); P = 0.03]. exPHT improved risk stratification in early-stage disease (stages 1–2), conferring an approximately five-fold higher risk of HF events in patients with exPHT [HR 4.45 (1.58–12.59); P < 0.01]. Conclusion: In patients with ≥ moderate AS and discordant symptoms, cardiac damage stage and exPHT independently refined HF risk stratification. ExPHT provides incremental prognostic value in early damage stages (1–2), representing over half of the cohort, supporting a stepwise approach of routine damage staging with selective with exPHT assessment with exercise echocardiography in this subgroup to guide more personalized management and potentially optimize AVR timing.

Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.

Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.

Background: Exercise-induced pulmonary hypertension (PH), defined by a mean pulmonary arterial pressure over cardiac output (mPAP/CO) slope >3 mmHg/L/min has important diagnostic and prognostic implications. Aims: The aim of this study is to investigate the value of the mPAP/CO slope in patients with at least moderate primary MR with preserved ejection fraction and no or discordant symptoms. Methods: A total of 184 consecutive patients were evaluated with exercise echocardiography and cardiopulmonary testing. Clinical outcome was defined as the composite of mitral valve intervention, new-onset atrial fibrillation, cardiovascular hospitalization, and all-cause mortality. Results: Mean age was 63 years, 59% male, and mean LVEF 67 ± 6%. The mPAP/CO slope correlated with peak VO2 (r = −0.37, P < .001), while peak sPAP did not (r = −0.05, P = .517). Thirty-nine per cent (n = 73) had peak exercise sPAP ≥60 mmHg, and 32% (n = 58) had mPAP/CO slope >3 mmHg/L/min. Event-free survival was 71% at 1 year and 59% at 2 years, with more clinical events in patients with mPAP/CO slope >3 mmHg/L/min (HR of 4.1 (95% CI 2.6–6.5). In 61 patients, mPAP/CO slope and peak sPAP were discordant. Patients with slope >3 mmHg/L/mmHg and sPAP 3 mmHg/L/min is associated with decreased exercise capacity and higher risk of adverse events in significant primary MR and no or discordant symptoms. The slope provides a greater prognostic value than single sPAP measures and peak VO2.