• History: to assess symptoms consistent with stable or unstable angina, presence of risk factors for IHD, as well as the type of sports in which the athlete participates, and family history of IHD/SCD.

• Resting ECG and provocative testing: with symptom-limited exercise testing (by treadmill or bicycle) for evaluation of ischaemia-threshold, symptoms, ST–T changes, BP and heart rate response, exercise capacity, and arrhythmias. Exercise testing or pharmacological stress testing with SPECT may show (ir)reversible perfusion defects of the myocardium, and exercise or pharmacological stress testing with echocardiography (or MRI) may show reversible regional wall motion abnormalities.

• Echocardiography: to assess global LV function, regional wall motion abnormalities, and/or associated structural cardiac anomalies.

• Coronary angiography: is mandatory in individuals with IHD willing to participate in competitive sports. Luminal coronary stenosis/occlusion, coronary flow disturbances or abnormal coronary anatomy should be evaluated.

• 24 H Holter monitoring (including a training session): to assess arrhythmias or silent ischaemic changes.

Risk stratification On the basis of the results of diagnostic testing the risk may be stratified⁷¹ as follows.

• Low probability for exercise-induced adverse cardiac events if all the following criteria are present:

  • ejection fraction >50% on echocardiography or on SPECT;

  • normal exercise capacity according to age and gender on exercise testing;

  • absence of exercise-induced ischaemia on ECG/stress testing at lower steps;

  • absence of frequent, complex ventricular tachyarrhythmias at rest and during stress testing;

  • absence of significant coronary stenosis (i.e. >70% of major coronary arteries, or >50% of left main stem) on coronary angiography.

• High probability for exercise-induced adverse cardiac events if one or more of the following criteria are present:

  • ejection fraction <50% on echocardiography or on SPECT, or

  • exercise-induced ischaemia (>1 mm ST depression in two leads) on exercise testing at lower steps, or

  • exercise-induced pathological dyspnoea (angina equivalent), or syncope, or

  • frequent, complex ventricular tachyarrhythmias at rest and/or during stress testing, or

  • significant coronary stenosis of major coronary arteries (i.e. >70%) or left main stem (>50%) on coronary angiography.

Specific comments

• Athletes with clinical unstable angina have a high risk for future CV events.

• Post-CABG/PCI athletes, who do not show evidence of myocardial ischaemia on stress testing, are allowed to resume physical activity under supervision of a sports physician after completion of an out-patient cardiac rehabilitation programme. Before entering sports activity, however, they need to be risk-stratified as specified earlier.

• The incidence of SCD in symptomatic or asymptomatic post-MI individuals is equal. Coronary angiography in SCD survivors and athletes after MI must be performed before they resume or initiate sports activity. In general, these athletes should be risk-stratified as specified earlier.

• Silent ischaemia increases the risk for cardiac arrest during physical stress similarly to symptomatic IHD. After establishing presence of true ischaemia, the patient should be risk-stratified as outlined earlier.

Recommendations See Table 8.

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Table 8 Recommendations for competitive sport participation in athletes with IHD

  Athletes without evidence of IHD, but with one or more risk factors for IHD In asymptomatic subjects without evidence of IHD, but in the presence of known risk factors, assessment of the risk profile is needed. The risk for IHD can be estimated from the presence of major risk factors including age, sex, BP, smoking, and total cholesterol level, according to the SCORE-system⁷² or as outlined in Table 6.

The high-risk profile for developing a fatal CV event is defined by: