Cardiomyopathy and exercise:
what physical activity can be done

Article written and reviewed by Dr Luca Moretti

Having cardiomyopathy does not automatically mean having to give up all physical activity. Current guidelines recommend avoiding a sedentary lifestyle and prescribing exercise individually, because the safe level of activity depends on the type of cardiomyopathy, the presence of symptoms, cardiac function, arrhythmias, any myocardial fibrosis and the response to exercise.
For many clinically stable people, light- or moderate-intensity aerobic activities such as brisk walking, cycling or progressive exercise may be possible. Intense or competitive sport, however, requires a specific assessment and recommendations may differ greatly among hypertrophic, dilated and arrhythmogenic cardiomyopathy.

Before deciding which activity to perform, it is necessary to consider:

• the exact type of cardiomyopathy and its cause;
• the presence of shortness of breath, chest pain, palpitations, dizziness or syncope;
• ventricular function and any obstruction to blood flow;
• the presence of arrhythmias at rest or during exercise;
• the amount and distribution of fibrosis on cardiac MRI when available;
• any genetic variants associated with greater arrhythmic risk;
• the type, intensity and dynamic or static component of the desired sport.

Cardiomyopathies are not a single disease. Therefore, a rule that applies to everyone, such as "no sport" or "you can do anything if you feel well", would be incorrect. The choice must begin with the diagnosis and individual risk stratification.

How much exercise can be done with cardiomyopathy?

European recommendations identify regular physical activity as part of a healthy lifestyle even in people with heart disease. As a general reference, moderate activity distributed throughout the week, for at least 150 minutes per week, is encouraged in people who are able to tolerate it. However, this figure is not an automatic prescription for someone with cardiomyopathy: in some patients it will be appropriate, in others the intensity or duration will need to be lower, whereas carefully selected people may be able to perform more demanding activity.
The most important principle is that volume and intensity should be increased gradually, avoiding sudden transitions from a sedentary lifestyle to strenuous exercise.

For many stable people, controllable dynamic activities such as walking, stationary cycling, cycling on non-demanding routes or recreational swimming are reasonable if there are no individual contraindications. Strength exercises may also be part of the program, but the load must be appropriate and should not be confused with maximal lifting or prolonged straining while holding the breath.
Intensity should not be chosen solely on the basis of age or general heart-rate formulas. Medications such as beta-blockers alter the heart-rate response to exercise, and in some patients the most reliable method for defining training zones is an exercise test, possibly with cardiopulmonary testing.

Which assessments are needed before exercising?

A person with cardiomyopathy who wants to exercise regularly, especially at high intensity, should have an up-to-date assessment. Medical history, physical examination, ECG and echocardiography are generally considered; depending on the phenotype, Holter monitoring, cardiac magnetic resonance imaging and an exercise test may be useful to assess functional capacity, blood pressure, the onset of symptoms and arrhythmias during exercise.
The test is particularly useful because a person may feel well at rest but develop arrhythmias, obstruction or an abnormal blood-pressure response only when the workload increases.

The decision must also take the specific sport into account. Running, hiking, weightlifting, playing football and diving do not place the same type of stress on the heart. Moreover, in activities in which loss of consciousness could cause a serious accident, even a relatively low risk may have different consequences from an activity performed in a controlled environment.
Having an implantable defibrillator does not eliminate the substrate that can cause an arrhythmia and should not be interpreted as automatic authorization to exercise without limitations.

Hypertrophic cardiomyopathy: recommendations are no longer the same for everyone

In hypertrophic cardiomyopathy, modern recommendations are less restrictive than in the past. Light- or moderate-intensity recreational exercise is generally encouraged in clinically stable people, and prospective studies have shown that controlled programs of moderate activity can improve physical capacity without showing an increase in serious events in the populations studied.
Vigorous activity is also no longer considered automatically prohibited for every person with hypertrophic cardiomyopathy. In selected patients with a mild phenotype and a favorable risk profile, it may be discussed after specialist assessment and shared decision-making.

This does not mean that risk is the same for everyone. Suspicious syncope, ventricular arrhythmias, significant outflow obstruction, marked hypertrophy, reduced systolic function, extensive fibrosis or other risk markers can substantially change the recommendation.
A person who is genetically positive but has no structural manifestations must also be followed over time because the phenotype may appear later. The presence or absence of symptoms during training is not sufficient on its own to determine suitability for intense exercise.

Dilated cardiomyopathy: physical activity is possible, but after stabilization

In dilated cardiomyopathy, moderate aerobic activity can improve functional capacity and quality of life when the patient is clinically stable and treatment has been optimized. The available evidence derives in part from studies of heart failure with reduced ejection fraction, in which structured exercise is part of rehabilitation.
If there are significant symptoms, recent deterioration, complex arrhythmias, very impaired ventricular function or clinical instability, exercise should instead be reduced or stopped until the situation has been reassessed.

High-intensity sport is not automatically appropriate even when a person with dilated cardiomyopathy feels well. Guidelines allow greater freedom especially in asymptomatic people with mild dysfunction, without exercise-induced arrhythmias and without significant myocardial fibrosis. Some genotypes associated with high arrhythmic risk require particular caution even when ventricular function is relatively preserved.

Arrhythmogenic cardiomyopathy: why intense exercise is a special case

Arrhythmogenic cardiomyopathy represents the most important exception to a very liberal approach to exercise. In this disease, intense exercise, especially endurance exercise, can increase mechanical stress on the myocardium, promote progression of the phenotype and increase the risk of ventricular arrhythmias.
For this reason, guidelines discourage high-intensity exercise and competitive sport in people with an arrhythmogenic phenotype. Caution also extends to some carriers of pathogenic variants without yet evident disease because a high training load may facilitate expression of the phenotype.

This does not mean prescribing complete inactivity. Light- or moderate-intensity activity may be possible in many people, but intensity and volume should be discussed with an experienced center. The recommendation depends on genotype, right and left ventricular involvement, the presence of fibrosis and the individual arrhythmic history.

When to stop during physical activity

During exercise, activity should be stopped if chest pain, fainting or near-fainting, persistent palpitations, sudden or much greater than expected shortness of breath, marked weakness or a clear deterioration in physical capacity occurs. These symptoms do not necessarily prove the presence of a serious arrhythmia, but they should not be ignored in a person with cardiomyopathy.
If the symptom is severe, persists after exercise is stopped or is associated with loss of consciousness, severe breathing difficulty or significant chest pain, calling 112 or 118 is appropriate.

Even in the absence of symptoms, it is useful to reassess the exercise program periodically, especially if the level of activity increases or the sport changes. Cardiomyopathy can evolve over time, and a prescription that was appropriate several years earlier is not necessarily valid forever.

Frequently asked questions about cardiomyopathy and exercise

Can someone with cardiomyopathy exercise?
Often yes. In most cases, a sedentary lifestyle is not recommended, but activity must be adapted to the individual phenotype and risk.

Is walking allowed?
For many stable people, light- or moderate-intensity walking is appropriate, with intensity and duration established according to functional capacity.

Can someone go to the gym?
It may be possible, but the program must distinguish aerobic exercise, moderate strength training and maximal efforts. The latter may be discouraged in some patients.

Does arrhythmogenic cardiomyopathy allow intense exercise?
In general, no: intense exercise and competitive sport are discouraged because they can increase arrhythmic risk and disease progression.

Which symptoms require stopping?
Chest pain, syncope or presyncope, prolonged palpitations, sudden shortness of breath and marked weakness require stopping the activity and appropriate assessment.