Physical activity and even elite sports should not automatically be ruled out for children with cardiomyopathy, the American Heart Association has said in a new scientific statement.
Evolving evidence supports the need to take a more personalised approach to advice on physical activity, one that considers disease phenotype, arrhythmic risk markers and the importance of shared decision-making between clinicians, patients and families, it advises.
The statement also stresses the need to balance risk factors with the “known short- and long-term detrimental consequences of a sedentary lifestyle in young patients,” adding that long-term “fear-based avoidance of physical activity” may have led to both unhealthy lifestyle behaviours and greater risk of acquired cardiovascular disease in this population.
“Decades of risk-averse clinical guidance have resulted in widespread PA restriction due to fears of sudden cardiac death and disease progression,” the AHA said.
“However, emerging data challenge this restrictive paradigm, showing that the risk of sudden cardiac death may not be higher in some patients with cardiomyopathy who exercise than in those who are less active, and that participation in PA may also have a positive effect on reverse remodeling.”
To date, a more personalised evaluation of the risk of physical activity in cardiomyopathy has been complicated by the fact that much of the existing research base has been focused on adult patients.
In addition, children wanting to increase their activity levels through exercising and those looking to train as athletes will have different risk profiles.
In the case of the former, the AHA has backed use of the FITT principle (frequency, intensity, time, type), which already underpins cardiac rehabilitation in the UK, as an intervention mode.
The statement also covers disease-specific recommendations, as well as separate guidance for children with implantable cardioverter defibrillators (ICD).
It notes that, while most of the available evidence on exercise in cardiomyopathy focuses on hypertrophic cardiomyopathy (HCM), other disease types carry specific risks and require bespoke approaches.
In particular, restrictive cardiomyopathy (RCM), arrhythmogenic cardiomyopathy (ACM) and certain types of genotypically defined dilated cardiomyopathy (DCM) have limited paediatric data.
This makes it more important for exercise prescriptions to consider individual risk assessments taking into account factors such as arrhythmic history, ventricular function, and likelihood of adherence to recommendations, the AHA stressed.
While the authors offer separate clinical recommendations for the four main disease subtypes, they share an emphasis on baseline evaluation, risk stratification and surveillance as part of a shared decision-making process.
Looking forward, further evidence and data pertaining to the safety of physical activity in children with cardiomyopathy is required to enable a more personalised approach to the disease, the AHA said.
“Given the limited data regarding physical activity safety in children and adolescents with cardiomyopathy, as much of the evidence is derived from adult studies, further studies assessing potential risks and benefits of habitual physical activity and moderate to intense exercise focused on paediatric patients are needed.”
The full statement is published in Circulation [link here].