2026 AHA科学声明：儿童心肌病的体育活动-运动健康

Table 1. Classifications of Physical Activity and the Exercising Individual

|Physical activity and classifications|Definition|Child or adolescent examples| |---|---|---| |The physical activity hierarchy||| |Physical activity|Any bodily movement produced by skeletal muscles that results in energy expenditure|Active living activities; walking between classes at school, chores at home; jogging, swimming, team sports| |Exercise|A subcategory of physical activity that is planned, structured, repetitive, and intentional for the purpose of improving or maintaining ≥1 components of physical fitness¹|| |Aerobic|Exercises that use large muscle groups, can be maintained continuously, and are rhythmic in nature$^{2}$; associated with an elevated volume load|Walking, jogging, or bike riding; elliptical or other cardio equipment; swimming| |Anaerobic|Intense exercise of short duration, fueled by the energy sources within the contracting muscles and independent of the use of inhaled oxygen as an energy source$^{2}$; can be associated with an elevated volume or an elevated pressure load|High-load resistance training († pressure load); jumping, trampoline activities; sprint training; dodging, chasing, and fleeing games| |Sport|Exercise involving gross motor movement that is rule governed, structured, and competitive$^{3}$; associated with an elevated volume or pressure load, or both (depending on the sport)|Recreational or community league sports; pick-up sport games; high school, club, or competitive sports| |The exercising child or adolescent||| |Exerciser|≥2.5 hrs/wk exercise (any type) with the intention to maintain health and fitness|Routine walking, jogging, or biking; fitness class; routine exercise at a gym or fitness center; cardiac rehabilitation| |Athlete|The athlete differs from the exercise on the basis of 3 criteria: Intent: athletic or physical performance versus health and fitness Volume of exercise: athletes have greater volume, resulting in greater hemodynamic stress and distinctive physiologic adaptation Level of competition: competitive versus noncompetitive or minimally competitive|| |Recreational|≥4 hrs/wk exercise for pleasure or fitness, or unregulated $competition^{4}$|Intramural sports; pick-up games; recreational or community league sports| |Competitive|≥6 hrs/wk exercise with an emphasis on improving performance and participating in official $competitions^{4}$|Competitive youth club sports; high school athletes; most college athletes| |Elite|≥10 hrs/wk exercise and athletic performance at the highest level of $competition^{4}$|Members of regional or national teams; Olympians; professional athletes; high-level college athletes|

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sport-related exercise-as well as its frequency, intensity, and duration, is essential for estimating volume and pressure loads on the heart, catecholamine load, and the resulting physiologic adaptations.

DISEASE-SPECIFIC RECOMMENDATIONS

Most available data on exercise in cardiomyopathy-particularly in children-focus on HCM, but other types of cardiomyopathies carry distinct risks and require nuanced approaches. For restrictive cardiomyopathy (RCM), ACM, and certain types of genotypically defined DCM, pediatric data are particularly limited, and recommendations are largely extrapolated from adult series and expert opinion. Therefore, exercise prescriptions for patients with these subtypes can consider emphasizing individualized risk assessment that integrates arrhythmic history, ventricular function, developmental maturity, and likelihood of adherence to recommendations, as well as family preferences, and clinicians can clearly communicate when guidance is based on limited or no pediatric evidence. The following disease-specific sections are designed not only to promote safe engagement in daily PA but also to guide clinicians in counseling pediatric patients and families who are considering higher levels of structured exercise or competitive or elite-level sport participation.

Hypertrophic Cardiomyopathy

HCM accounts for 3% to 24% of cases of SCD in young individuals.$^{1-3}$ Concerns that participating in PA or sport could increase the risk of SCD or precipitate disease progression have historically contributed to a pattern of activity restriction. This has come with substantial costs, as children and adolescents with HCM may develop impaired exercise capacity$^{6}$ and an increased risk for poor cardiometabolic health due to exercise restrictions.$^{9}$ Furthermore, reduced levels of PA are associated with lower measures of QoL$^{10}$ and worse indices of mental health,$^{24,25}$ emphasizing the bidirectional relationship between PA and emotional well-being in children.

The traditional recommendation to restrict PA in pediatric patients with HCM has been challenged. A retrospective cohort study of young people with HCM found that SCD was more likely to occur during rest or sleep than while exercising.$^{26}$ Given the comparative time that children spend sleeping or at rest in comparison with being physically active, exercise may still present a higher risk per time of exposure than rest or sleep. However, the risk of SCD does not appear to be higher in people who exercise vigorously or competitively than in those who are less active.$^{27}$ In the prospective LIVE-HCM registry,$^{27}$ among 259 vigorous competitive athletes included, 93 (35.9%) were <18 years of age and 31 (12.0%) were 18 to 25 years of age. The study met noninferiority for the composite arrhythmic end point for vigorous versus

nonvigorous activity overall, and vigorous competitive participation was also not associated with higher risk (hazard ratio, 0.71 [upper 95% 1-sided confidence level, 1.32]). Event numbers in children were small, and most sudden cardiac arrest (SCA) or SCD events in the cohort did not occur during competition, underscoring both potential safety and the need for individualized evaluation. Accordingly, and consistent with the 2025 AHA/ACC scientific statement,$^{18}$ participation in competitive sports can be reasonable for carefully selected pediatric patients with HCM following expert assessment and SDM. A pragmatic pediatric pathway$^{17}$ includes the following:

1. Screen and stage-perform a comprehensive history and examination, with ECG, echocardiogram, or cardiac magnetic resonance imaging (CMR), as indicated; identify classic HCM risk markers (eg, maximum wall thickness, nonsustained ventricular tachycardia, syncope, family history of SCD, extensive late gadolinium enhancement burden, left ventricular [LV] outflow tract gradients)

2. Optimize-manage LV outflow tract obstruction and symptoms (β-blocker or calcium channel blocker; septal reduction when indicated); treat arrhythmias; ensure blood pressure and hydration strategies

3. Decide (SDM)—engage in sport-specific risk discussion (eg, intensity, duration); consider athlete and family values; establish an emergency action plan with on-site automated external defibrillator access

4. Clear and condition-prescribe gradual training with attention to heat or illness, stimulant use, deconditioning

5. Monitor-reassess every 6 to 12 months or sooner if symptoms change; consider Holter and event monitoring around season start; genotype-positive/phenotype-negative (G+/P-) individuals may generally participate without restriction, with periodic surveillance

Small interventional studies suggest favorable cardiac remodeling with exercise in adults with HCM, although data are preliminary and heterogeneous. A 12-week randomized trial in nonobstructive HCM demonstrated reduced LV filling pressures during exercise and improved peak cardiac index with supervised moderate-intensity training, whereas a randomized trial comparing high- versus moderate-intensity training showed an increase in LV end-diastolic volume with high-intensity training, consistent with favorable cardiac adaptation.$^{28,29}$. Overall, there is emerging evidence of hemodynamic and potentially structural favorable remodeling with supervised exercise, but definitive proof of consistent reverse remodeling in HCM is limited, and longer, adequately powered trials are needed in a pediatric population.$^{28,29}$ Acute exercise is associated with increased sympathetic activation, elevated heart rate, and higher circulating

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catecholamines-factors that could theoretically increase arrhythmia risk in susceptible $individuals^{30}-but$ long-term habitual PA induces favorable autonomic adaptations, including higher resting vaginal tone and reduced sympathetic drive at rest and during submaximal exertion. This phenomenon, sometimes referred to as the “exercise paradox,” posits that although the acute phase of exercise may transiently elevate arrhythmic risk, the chronic adaptations conferred by improved cardiovascular fitness may lower overall arrhythmogenic susceptibility in the long $term.^{31}$

A changing landscape with respect to PA and HCM-from one of restriction to one that promotes PA-has been motivated by 3 considerations: restriction has negative consequences related to overall cardiometabolic health and may have social and emotional costs for the patient; the risk of SCD may not be higher in individuals who exercise vigorously or competitively than in those who are less active; and participation in PA may have a positive effect on reverse remodeling. Thus, the challenge in caring for children and adolescents with HCM is to determine their level of risk, and to guide the patient and family through a SDM process. Several factors, including age, symptoms, family history, disease morphology, childhood environment, and electrophysiologic testing results, can be used to help clinicians and families make informed decisions about PA, exercise, and sports participation for patients with HCM.$^{4.5}$

The AHA/ACC guideline for the management of HCM$^{32}$ defines several risk factors for SCD in HCM, including a personal history of SCA or sustained ventricular arrhythmias, unexplained syncope, family history of premature (<50 years of age) HCM-related sudden death, maximal LV wall thickness ≥30 mm in any segment, systolic dysfunction with ejection fraction <50%, LV apical aneurysm, nonsustained ventricular tachycardia on continuous ambulatory ECG monitoring (≥3 beats at ≥120 bpm), and late gadolinium enhancement comprising ≥15% of LV mass on CMR.$^{4.6}$ HCM with reduced systolic function is relatively rare in children; however, these patients are known to be at higher risk for arrhythmia and SCD.$^{32}$ Therefore, ventricular dysfunction should be addressed and incorporated into risk stratification when offering recommendations about participation in PA or sports. Studies have also shown that exercise stress testing is a useful tool for risk assessment in children and adolescents with HCM, with ST-segment changes during exercise associated with an increased risk of SCD.$^{33}$. Therefore, for young athletes and exercisers with HCM, a comprehensive evaluation including personal and family history, CMR, ambulatory rhythm monitoring, and provocative exercise testing can help guide an individualized risk assessment.$^{33}$ A similar framework can be applied to patients with HCM and a restrictive phenotype. Given that the risk of SCD in HCM is never zero, young patients with HCM who are exercisers or participating in sport

can consider having a comprehensive emergency action plan for SCA that includes access to an automated external defibrillator and training of potential rescuers who are with the patient during exercise (ie, coaches) in prompt recognition of SCA, cardiopulmonary resuscitation, and automated external defibrillator use.$^{9,10}$

Several risk calculators are available to estimate SCD risk in patients with HCM (Table 2), including children and young adults, and can be used to help quantify disease severity in individual $patients.^{34-38}$ These tools are meant to clarify disease-specific risk of a future cardiac event, but do not provide information on how participating in PA or sport potentially influences that risk. Furthermore, exercise testing is not included in any of these risk calculators, which potentially limits their ability to provide information about PA-specific risk.

Studies assessing the safety of PA or intense exercise in pediatric patients with HCM are limited,$^{39}$ but light- to moderate-intensity PA and exercise is encouraged, and expert guidelines have uniformly put forth the recommendation that sport participation and high-intensity exercise are reasonable to consider in patients with HCM.$^{78}$ Regardless of disease severity, the goal for all pediatric patients with HCM is to identify and promote forms of PA that are compatible with the patient's desires and abilities, while acknowledging what is known about the patient-specific risk of SCD.

Dilated Cardiomyopathy

In adults with DCM, randomized trials and meta-analyses show improvements in functional capacity, measures of cardiac function, and health-related QoL with structured exercise training, paralleling the HCM evidence base. Supervised aerobic training consistently increases $VO_2\text{peak}$ and exercise duration in patients with DCM, as highlighted in studies such as HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) and smaller DCM-focused trials, which demonstrate ~15% to 20% gains in $VO_2\text{peak}$ after 2 to 5 months of training.$^{34-38}$ Furthermore, invasive exercise hemodynamics demonstrate improvements consistent with favorable central and peripheral adaptations, and exercise training has been associated with improved LV ejection fraction, reduced LV volume, and enhanced LV work efficiency, whereas myocardial high-energy phosphate ratios generally remain unchanged, indicating positive energetic adaptations.$^{40-44}$ Exercise-based cardiac rehabilitation has been shown to improve health-related QoL, and is endorsed by the ACC, AHA, and Heart Failure Society of America, and supported by randomized clinical trials and meta-analyses.$^{40,45}$

Evidence in children with DCM is limited but directionally consistent with evidence in adults: structured PA appears feasible and associated with better functional capacity and health status. However, pediatric randomized

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Table 2. Risk Stratification in Children and Adolescents with Cardiomyopathy

|Cardiomyopathy type|Risk stratification|Risk stratification|Risk stratification| |---|---|---|---| |Cardiomyopathy type|Diagnostic tools|Personal and family history|Risk calculators| |HCM|ECG, TTE, CMR, CPET, ambulatory ECG monitor, genetic testing, family screening|Exertional chest pain, dyspnea, syncope, palpitations; family history of premature SCA or SCD &lt;50 y|HCM Risk-Kids (age 1-&lt;16 y):https://hcmriskkids.orgPRIMaCY (age &lt;18 y):https://primacycalculator.comAHA HCM SCD Calculator (age ≥16 y):https://professionalheart.org/en/guidelines-and-statements/hcm-risk-calculatorHCM Risk-SCD Calculator$^{3a}$ (age ≥16 y): https://pubmed.ncbi.nlm.nih.gov/26216213/| |DCM|ECG, TTE, CMR, CPET, ambulatory ECG monitor, genetic testing, family screening|Comprehensive assessment of symptoms at rest and with activity (NYHA or Ross class)|| |ACM|ECG, TTE, CMR, CPET, ambulatory ECG monitor, genetic testing, family screening; cardiac biopsy; electro-anatomic mapping|Comprehensive assessment of symptoms at rest and with activities; family history of SCD|ARVC Risk Calculator:https://arvcrisk.com/;ITFC risk stratification algorithm| |RCM|ECG, TTE, CMR, CPET, ambulatory ECG monitor, genetic testing, family screening|Comprehensive assessment of symptoms at rest and with activity (NYHA or Ross class); Family history of SCD||

ACM indicates arrhythmogenic cardiomyopathy; AHA, American Heart Association; ARVC, arrhythmogenic right ventricular cardiomyopathies; CMR, cardiac magnetic resonance imaging; CPET, cardiopulmonary exercise testing; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; ITFC, International Task Force Consensus; NYHA, New York Heart Association; PRIMaCY, Precision Medicine in Cardiomyopathy; RCM, restrictive cardiomyopathy; SCA, sudden cardiac arrest; SCD, sudden cardiac death; and TTE, transtrhoracic echocardiogram.

trials showing definitive improvements in cardiac structure and function are lacking. Children and adolescents with inherited cardiomyopathies (including DCM) demonstrate lower $VO_{2}peak$ and lower moderate; to vigorous-intensity PA than matched controls; higher habitual PA correlates with higher $VO_{2}$; and lower fitness level and PA are associated with worse health metrics, supporting the potential for capacity gains with PA and rehabilitation approaches in pediatric cohorts.$^{746}$ Moreover, the negative sequelae of immobilization in these patients is well-established,$^{44,47-49}$ and studies in children with DCM have shown that PA and exercise is generally well-tolerated and improves both cardiometabolic health and $QoL.$^{16}$ Even for children with DCM and refractory heart failure who are awaiting heart transplant, exercise has an important role in pretransplant conditioning and on posttransplant outcomes.$^{50,51}$ Cardiac rehabilitation is feasible in patients with DCM, even for those on inotropes and mechanical circulatory support, and has not been shown to increase the risk of adverse events.$^{15,52-54}$

For some children with DCM, particularly those with variants known to be associated with a heightened risk of arrhythmias, such as LMNA/C, DSP, or FLNC,$^{55}$ ambulatory rhythm monitoring and provocative exercise testing are helpful components in the risk assessment for participation in PA and exercise. Closer surveillance may be indicated in some children with DCM, such as those with arrhythmogenic genetic subtypes of DCM, substantial fibrosis on CMR, severely depressed ventricular function, or symptoms associated with exercise.

Compared with adult athletes, children and adolescents with DCM present with different pathogenesis (eg, genetic, myocarditis, neuromuscular disease), a higher likelihood of recovery or remodeling, and fewer comorbidities. Arrhythmic risk markers are less well validated in pediatrics, and risk calculators derived from adult cohorts do not directly apply. Thus, management decisions in pediatric athletes with DCM require a tailored approach.

Actionable clinical considerations for pediatric DCM and PA include the following:

1. Baseline evaluation: ECG, echocardiogram, consideration of CMR to assess ventricular size, function, scar, and arrhythmic substrate; genetic testing when appropriate

2. Risk stratification: identification of higher-risk features (eg, ejection fraction <35%, clinically significant ventricular arrhythmias, history of syncope, marked LV dilation)

3. Therapy optimization: guideline-directed medical therapy, rhythm management, device consideration (implantable cardioverter defibrillator [ICD] or cardiac resynchronization therapy) when indicated

4. SDM: in patients with mild LV dysfunction and no high-risk features, recreational and structured PA is reasonable; competitive or elite-level sport may be considered in patients with normal findings or mild dysfunction, no arrhythmias, and expert oversight

5. Ongoing monitoring: pediatric patients with DCM may undergo serial assessment every 6 to 12

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months, with earlier reevaluation if symptoms evolve; PA recommendations may be revisited as myocardial function may improve or deteriorate. These considerations emphasize both safety and the potential benefits of PA. In contrast to adult athletes with DCM-who often present with chronic, nonreversible LV dysfunction-children and adolescents may experience recovery or dynamic changes in ventricular function, supporting a more flexible, longitudinal approach to sports participation.

Restrictive Cardiomyopathy

RCM, the rarest type of pediatric cardiomyopathy, accounts for $\approx 2.5\%$ to 5% of cases.$^{56}$ RCM is characterized by marked diastolic dysfunction due to myocardial stiffness, resulting in elevated ventricular filling pressures despite preserved or near-preserved systolic function. Children typically present with exercise intolerance and fatigue, with cardiac output augmentation limited to heart rate increases due to fixed LV volumes. This physiology is frequently accompanied by atrial and ventricular arrhythmias, pulmonary hypertension, and progressive diastolic heart failure. Mortality rates are high, with many patients listed for transplant soon after diagnosis.

There are no randomized trials or prospective cohort studies evaluating PA or exercise safety or exercise interventions in pediatric RCM. The available literature consists largely of case reports and small adult series.$^{57-60}$ Given the combination of limited cardiac reserve, high arrhythmic risk, and potential for rapid deterioration, high-intensity competitive or elite-level sports are generally discouraged. Risk stratification can consider arrhythmic history, functional status, presence of pulmonary hypertension, patient values, and transplant candidacy. For clinically stable patients without high-risk features, light- to moderate-intensity exercise-such as walking, light cycling, or swimming-may be appropriate to maintain conditioning and QoL, ideally under medical supervision or within a structured cardiac rehabilitation program. Decisions can be individualized, incorporate patient and family preferences, and be reevaluated at regular follow-up.

Arrhythmogenic Cardiomyopathy

In individuals with ACM,$^{11}$ the frequency of ventricular arrhythmias is often out of proportion to the degree of right ventricular or LV dilation or systolic dysfunction, and the risk of SCA among athletes with ACM varies by genotype. For individuals with ACM caused by PKP2 variants, vigorous-intensity aerobic exercise has been associated with a higher risk of SCA and potential acceleration of structural disease progression in retrospective studies.$^{61-63}$ The evidence for increased

SCA risk or disease acceleration with participation in vigorous exercise is less well established for other genetic forms of ACM or for genotype-negative ACM. Accordingly, published guidelines and scientific statements have been cautionary in their recommendations for sports participation among individuals in whom the risks may outweigh the benefits (eg, PKP2-mediated ACM).$^{64}$

The case of G+/P- children, often identified through cascade screening after a parent or sibling is diagnosed, poses a particular challenge. Parents frequently ask whether their G+/P- child can participate in unstructured PA or exercise such as riding bikes, playing soccer with friends, or participating in recreational sports. Evidence and expert consensus support the following principles:

1. Reassurance for daily play: For G+/P- children, unstructured play, recreational PA and exercise, and physical education can be encouraged. These activities promote cardiometabolic and psychosocial health and are not restricted.

2. Sports: There is no evidence that sports participation accelerates disease onset; however, because arrhythmic risk is genotype-dependent and penetrance is variable, competitive or elite-level sport participation requires careful, individualized consideration.

● Factors to consider include gene-specific risk, family history of SCD, and availability of emergency response (eg, automated external defibrillator access, trained personnel).

• SDM with families is essential.

3. Surveillance: G+/P-youth require longitudinal monitoring (annual or biennial ECG or echocardiogram ± Holter monitoring or CMR depending on age and findings). Recommendations can be revisited regularly because phenotypes may emerge over time.

4. Risk stratification: Adult guidelines increasingly stratify risk by specific genetic variant. In pediatrics, gene-based recommendations are less validated, but certain variants (eg, PKP2, DSP, TMEM43) may warrant closer surveillance.

5. Parental counseling: Clinicians can explicitly reassure families that developmentally appropriate unstructured play-running around the playground, riding bikes, and engaging in physical education—is likely safe and clearly beneficial. The emphasis is therefore on participation in life rather than restriction.

As summarized in Table 3, routine play and light to moderate PA may be encouraged in nearly all patients with ACM, including G+/P- individuals. More restrictive recommendations apply primarily to patients with PKP2-mediated ACM and a clear phenotype, for whom high-intensity or endurance sports may confer elevated risk.

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Table 3. Actionable Steps for Shared Decision-Making for Physical Activity in Pediatric Cardiomyopathy

|SHARE element|Steps|Applied to physical activity in pediatric cardiomyopathy| |---|---|---| |Seek|Seek patient and caregiver participation in the conversation. Determine preferences specific to decision-making participation for the pediatric patient.|&quot;We can make decisions together regarding physical activity and sports participation in light of this new diagnosis. You have options. How would you like to be involved in discussing these options and decisions?&quot;| |Help|Help the patient and caregivers understand their individualized treatment options, as well as risk stratification pertaining to physical activity.|&quot;Let&#x27;s review the risks, benefits, and options specific to you, your condition, and your quality of life.&quot; Simple pictures and educational materials can be helpful for presenting options and risk stratification.| |Assess|Assess patient and caregiver values regarding physical, psychologic, and social considerations specific to physical activity.|&quot;It is important to know what matters most to you. What does a good day look like for you? What worries you about this decision or the options we discussed? When making decisions, what helps you?&quot;| |Reach|Reach a decision together with the patient, caregivers, and clinical care team.|&quot;What additional information may be helpful for you to make this decision? Based on what you have shared regarding what matters to you, which option do you prefer? Together, given what have shared, we may consider...&quot;| |Evaluate|Evaluate the decision together with the patient and caregivers on an ongoing basis.|&quot;We will regularly touch base on this decision. We can always revisit this decision. What matters to you may change, and new options may present.&quot;|

Implantable Cardioverter Defibrillators

Children and adolescents with ICDs are often counseled to avoid exercise due to clinician concerns related to appropriate and inappropriate ICD discharge, increased likelihood of arrhythmias, and the potential for complications related to the integrity of the ICD leads.$^{65}$ This has likely contributed to the prevalence of anxiety and depressive symptoms seen in children and adolescents with ICDs.$^{66}$ Several studies of children and adults with ICDs describe avoidance of PA due to fear of shock from their device.$^{66-69}$ However, recent data show that most patients with ICDs can participate in PA and exercise without significantly increasing their risk for cardiac events, shocks, or damage to their device.

In a study of 372 athletes with ICDs (age 10–60 years) from the multinational ICD Sports Safety Registry, the authors reported shocks in 10% of patients associated with sports (5.6% appropriate shocks, 4% inappropriate shocks), with the ICD terminating all arrhythmias.$^{70}$ The incidence of shocks was higher during competition, practice, or PA than during rest (16% versus 6%; $\mathcal{R}<0.0001$), but there was no difference in the incidence of shocks during competition or practice when compared with other PA. Furthermore, there were no instances of death, resuscitated SCA, or shock-related injury during sport participation.$^{70}$ Thus, although patients observed in this study did experience ICD discharge with exercise, the ICD was effective, and there was no increase in lead complications. Further work with this registry has demonstrated freedom from lead malfunction in athletes of ≥92% at 5 years,$^{71}$ and that the incidence of ICD shocks was lower in recreational athletes compared with competitive athletes (13% versus 26%, respectively).$^{72}$ Sports with risk of contact or collision have the potential to cause damage to the device, and limitations may exist for children with ICDs who engage in exercises or sports with excessive overhead movements or requiring a full range of motion of the upper extremity, but general PA can be encouraged in pediatric patients with ICDs in place.

Special care must be taken when programming the ICDs of patients who are exercisers or athletes. Studies have shown that athletes with ICDs programmed with a high-rate cutoff had a decreased risk of total and inappropriate shocks during both sport competition and practice. Programming long-detection intervals was also associated with fewer total shocks, emphasizing that appropriate programming is key when caring for these patients.$^{73}$ Given the evidence that PA and exercise does not generally confer a substantial risk to either the child or the device, and the clear relationship of PA with emotional well-being in childhood, encouraging PA is important to mitigate the psychologic burden that comes with device implantation.

Data on athletes with ICDs largely come from the ICD Sports Registry, which included 440 athletes in its study, but only a small number were <18 years of age at enrollment. Thus, although registry findings suggest that sports participation is feasible and not associated with excess adverse outcomes, extrapolation to the pediatric population should be made cautiously. Unique pediatric considerations include:

● Growth and lead stress may result in a higher risk of lead fracture and need for lead revision than in adults.

● Psychosocial factors may influence participation, including fear of shocks, perceived stigma, body image concerns, and anxiety related to recreational or organized sports.

● Contact or collision sports carry theoretical risks of device or lead damage, but pediatric-specific data are lacking. Inappropriate or appropriate shocks were not more common during sport participation in registry studies, suggesting that historical restrictions may have been overly conservative.

The true risk in pediatric athletes with ICDs is not well-defined, but there is no evidence that participation in recreational or selected organized sports is unsafe. This uncertainty is to be communicated transparently, with ongoing follow-up and SDM guiding recommendations. Figure 2.

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 Figure 2. Proposed decision tree for physical activity in children with implantable cardioverter defibrillators in place. ICD indicates implantable cardioverter defibrillator; PA, physical activity; SDM, shared decision-making; SVT, supraventricular tachycardia; VF, ventricular fibrillation; and VT, ventricular tachycardia.


SHARED DECISION-MAKING

In pediatrics, SDM has been defined as a collaborative process by which health care clinicians, pediatric patients (depending on their psychosocial maturity and willingness to be involved), and the patient's parents or guardians make health-related decisions.$^{74,75}$ The American Academy of Pediatrics underscores 4 components of SDM in pediatric medicine: (1) ≥2 parties are involved; (2) information is exchanged across all parties; (3) all parties understand available treatment options (ie, choice awareness); and (4) knowledge, values, preferences, and goals of all parties equally inform the decision-making process.$^{76}$ Although SDM is foundational to family-centered pediatric health care, it is a complex process that is often not well implemented due to a range of cognitive and developmental patient considerations and parent or guardian decisional or legal rights, among other complicating factors.$^{76}$ SDM specific to genetic evaluations, PA, lifestyle, and treatment choices has been recommended in patients with HCM,$^{32}$ and has been shown to mitigate the decisional conflict and regret specific to decisions about exercise that many adults with cardiomy-opathies are known to experience,$^{77}$ further underscoring its importance.

To assist clinicians in conducting SDM around PA in this population, Table 4 outlines actionable steps for conducting SDM in pediatric cardiomyopathy using the SHARE (seek, help, assess, reach, evaluate) approach.$^{78}$

The following are additional specific strategies and considerations for effective SDM when caring for pediatric athletes and their families Figure 3:

● Clarity the decision point early in the conversation. For example, determine whether the primary question is whether the child can return to sports, increase daily PA or exercise, or pursue high-level competition. Being precise about the decision helps ensure shared understanding.

• Explore the child's or adolescent's desired level of involvement. Ask the patient directly (when developmentally appropriate) “Do you want to participate in this conversation and help make this decision?” Assess their maturity, understanding of their condition, and emotional readiness. Their preference to defer to their parents can also be respected as a valid choice.

• Normalize differing perspectives. It is common for patients, parents, and clinicians to have diverging priorities and risk tolerance. Invite each party to share what they value (eg, "What's most important to you about playing this sport?"), and their concerns (eg, "What are you worried might happen?"). Elicit values explicitly to guide risk and benefit framing.

● Acknowledge and explain uncertainty transparently (eg, "We cannot be 100% certain, but based on your child's testing results and overall condition, we think the risk of a serious event is low/moderate/high, and here's why...").

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Table 4. Exercise-Related Arrhythmic Risk and Physical Activity Guidance Across Pediatric Cardiomyopathy Subtypes

|Cardiopathy subtype|Key arrhythmic risks with exercise|Pediatric evidence|Summary| |---|---|---|---| |Hypertrophic|Ventricular arrhythmias (especially with LVOT obstruction), exercise-induced ischemia|Moderate evidence (observational pediatric and mixed-age cohorts)|Recreational PA generally recommended; competitive sport possible in select patients with shared decision-making| |Restrictive|High risk of atrial and ventricular arrhythmias; diastolic intolerance to exertion|Limited pediatric data; adult data show high arrhythmic risk|Avoid high-intensity or competitive sport; encourage low or moderate PA with close monitoring| |Arrhythmogenic*|Exercise accelerates disease progression and increases ventricular arrhythmia risk in PKP2-related ACM|Limited pediatric data; adult data robust for risk with endurance or high-intensity exercise for PKP2-related ACM|Avoid high-intensity or endurance sport in PKP2-related ACM and clear phenotype; light or moderate PA generally encouraged; shared decision-making essential| |Dilated: genotype-specific (eg, LMNA, FLNC)|Genotype-specific high SCD risk, especially with exertion (LMNA); variable by variation|Minimal pediatric data; genotype-phenotype correlations from adult cohorts|Tailor PA guidance to genotype and phenotype; caution with higher-risk genotypes; monitor with ambulatory rhythm assessment| |Idiopathic or other dilated|Arrhythmic risk generally proportional to LV dysfunction severity|Some pediatric observational data|Recreational PA encouraged if stable; competitive sport considered in absence of high-risk features|

*Restrictions on high-intensity or endurance sport apply primarily to patients with PKP2-mediated arrhythmogenic cardiomyopathy (ACM) and a clear phenotype or other high-risk features. Routine play and light- to moderate-intensity physical activity (PA) are generally encouraged for all patients with ACM, including genotype-positive/phenotype-negative individuals.

LV indicates left ventricular; LVOT, left ventricular outflow tract; and SCD, sudden cardiac death.

● Use individualized risk stratification as a tool, not a gatekeeper. Tools such as ECG, CMR, genetic testing, and stress tests can inform the conversation, but can be discussed in the context of the patient's own priorities (eg, "Your child's testing shows [X], which means the chance of an arrhythmia during exercise is [Y]. How does that make you feel about your decision?").

● Provide clear examples of safe and meaningful PA. Rather than framing the decision as binary (eg,

“play sports or not”), offer a spectrum (eg, “Here are ways we can keep your child active and satisfy their exercise-related goals that feel safe given what we know. Let's talk about which of these align with your family's goals.”).

● Follow-up and adapt. Emphasize that decisions are not fixed, and that circumstances, risk profiles, and goals may change, and the plan can be revisited. Acknowledge that ongoing emotional support,


Figure 3. A framework for shared decision-making around physical activity in children with cardiomyopathy.

Illustration of key components that support high-quality shared decision-making regarding physical activity (PA) in children with cardiomyopathy. This framework integrates clinical risk stratification with individualized discussion of benefits, uncertainty, and values, actively incorporates the child's preferences, and adapts recommendations through follow-up over time.

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especially after restrictions are imposed, is part of the care plan.

For the clinician, participation in SDM includes incorporating an understanding of the perceived patient-specific risks (based on genotype, arrythmia burden, baseline exercise ability, and personal or family history of SCD) and potentially protective factors (eg, medications, ICD, emergency action plan) to give an honest assessment.$^{71-76}$ Ultimately, SDM around PA in pediatric cardiomyopathy requires clinicians to move beyond generic recommendations and toward personalized, collaborative planning that integrates clinical evidence, patient and family values, and evolving goals. Thoughtful application of SDM can support better-informed, less stressful decisions and help preserve autonomy and QoL for children and families navigating uncertain terrain.

LONG IT U DINAL FOLLOW-UP

Phenotypic and clinical manifestations of a genetic cardiomyopathy may evolve through childhood and adolescent development. Thus, all children with a clinical diagnosis of a genetic cardiomyopathy, regardless of their level of PA and exercise participation, or desire to engage in sport, can consider undergoing a comprehensive assessment, including a personal and family history, physical examination, cardiac imaging, and exercise stress testing, with at least annual follow-up. A key part of this follow-up includes an assessment of the child's or adolescent's current and planned participation in exercise or sport. Engagement in PA, exercise, or sport can evolve and fluctuate as a child transitions from elementary school to middle school to high school, with more rapid fluctuations in PA among winter, spring, summer, and fall. More frequent surveillance is indicated in athletes whose conditions are evolving or progressing, or for whom medications are being added or dose-titrated. For pediatric patients with cardiomyopathy participating in competitive or elite-level sports, longitudinal follow-up may be enhanced by engagement in multidisciplinary sports cardiology programs, which can provide coordinated, individualized care and optimize safety and athletic performance.$^{1,7,79}$ Older adolescents and young adults with genetic heart diseases, particularly those competing at collegiate levels, often transition to adult sports cardiology programs. Collaborative evaluation with adult sports cardiologists is essential to maintain consistency in risk assessment and SDM across the age spectrum. Regardless of the degree of PA, exercise, or competition, new symptoms in any patient may prompt a pause in activity, training, and competition for reevaluation. Regular review of SDM preferences and risk stratification may occur. It is essential to recognize that a patient's or family's values and interests specific to PA may evolve throughout a patient's treatment, necessitating a return to SDM discussions.

FUTURE DIRECTIONS

All types of exercise, including sports and PA, contribute to volume and pressure loads on the heart, catecholamine load, and type of physiologic adaptation. Much of the literature on PA in youth with cardiomyopathy focuses on risk assessment and mitigation for athletes participating in sports. However, outside of sports participation, children and adolescents participate in varying levels of daily PA and exercise, from developmentally appropriate unstructured play in children to more structured bouts of exercise in adolescents (eg, playing basketball with friends, going to a fitness center). Future work is needed to develop tools to aid in the clinical assessment of a patient's overall PA, whether it be habitual PA versus exercise, or aerobic versus anaerobic, and the volume or dosage of that exercise, possibly with wearable technologies. In light of the rightful emphasis on SDM, tools that facilitate effective communication with patients, families, and sports teams, including risk communication aids, patient-facing PA clearance guides, and easily modifiable templates for emergency action plans, are warranted. Given the limited data regarding PA 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 PA and moderate to intense exercise focused on pediatric patients are needed. In addition, the impact of moderate-intensity aerobic exercise or vigorous-intensity exercise on the progression of DCM or the occurrence of SCA in pediatric patients with DCM has not been prospectively studied. Although research in ACM has shown that high-intensity endurance exercise is associated with a greater incidence of SCD and disease progression in people with the PKP2 variant, prospective studies are needed that explore the effect of exercise type on other genetic and genotype-negative forms of ACM.

The beneficial effects of PA and exercise on the cardiometabolic and mental health of children, adolescents, and adults with normal cardiac physiology are well established. Pediatric patients with cardiomyopathy receive the same cardiometabolic and psychologic benefits from PA and exercise, and clinically significant PA and exercise restriction is likely to lead to an increased risk of lifestyle-related cardiometabolic disease in adulthood. More studies are needed exploring the short- and long-term psychologic and cardiometabolic health effects of PA, exercise, and sport participation or disengagement in youth with cardiomyopathy. The ORCCA study (Outcomes Registry for Cardiac Conditions in Athletes) is monitoring athletes 14 to 35 years of age with cardiac conditions associated with SCD for major adverse cardiovascular events, QoL, and mental health.$^{80}$ Research such as this could lead to the development of evidence-based PA and exercise programming for youth with cardiomyopathy that provides essential evidence-based guidance.

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CLINICAL STATEMENTS AND GUIDELINES

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 19, 2025, and the American Heart Association Executive Committee on March 2, 2026. A copy of the document is available at https://professionalheart.org/statements by using either "Search for Guidelines & Statements" or the "Browse by Topic" area. To purchase additional reprints, call 215-356-2721 or email Meredith.Edelman@wolterskluwer.com

The American Heart Association requests that this document be cited as follows: Edelson JB, Baker-Smith CM, Cifra B, Cousino M, Day SM, Drezner JA, Dubin AM, Gates C, White DA, Conway J; on behalf of the Pediatric Heart

Failure and Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Clinical Cardiology; Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular and Stroke Nursing. Physical activity in pediatric cardiomyopathies: moving for health; a scientific statement from the American Heart Association. Circulation. 2026;153:e****-e****. doi: 10.1161/CIR.0000000000001431

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the "Guidelines & Statements" drop-down menu, then click "Publication Development."

Permissions: Multiple copies, modification, alteration, enhancement, and distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heart.org/permissions. A link to the "Copyright Permissions Request Form" appears in the second paragraph (https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers&#x27; bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Jonathan B. Edelson|The Children&#x27;s Hospital of Philadelphia|NIH (NIH K23 career development grant)†|None|None|None|None|None|None| |Jennifer Conway|Stollery Children&#x27;s Hospital (Canada)|None|None|None|None|None|None|None| |Carissa M. Baker-Smith|Nemours Children&#x27;s Hospital Delaware Cardiac Center, Center for Cardiovascular Research and Innovation|None|None|None|None|None|None|None| |Barbara Cifra|The Labatt Family Heart Centre, Hospital for Sick Children, Toronto (Canada)|None|None|None|None|None|None|None| |Melissa Cousino|University of Michigan, C.S. Mott Children&#x27;s Hospital|None|None|None|None|None|None|None| |Sharlene M. Day|University of Pennsylvania|None|None|None|None|None|None|None| |Jonathan A. Drezner|University of Washington|American Heart Association (ORCCA study)†; National Center for Catastrophic Sports Injury Research (division of Cardiac Injury in Sport)†|None|None|None|Ainthoven*|None|None| |Anne M. Dubin|Stanford University|None|None|None|None|None|None|None| |Corey Gates|Texas Children&#x27;s Hospital|None|None|None|None|None|None|None| |David A. White|Children&#x27;s Mercy Kansas City Ward Family Heart Center|None|None|None|None|None|None|None|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives ≥$5000 during any 12-month period, or ≥5% of the person's gross income; or (b) the person owns ≥5% of the voting stock or share of the entity, or owns ≥$5000 of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

+Significant.

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Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers&#x27; bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Shahnawaz Amdani|Cleveland Clinic Children&#x27;s Hospital|University of Michigan: The impact of Fontan circulatory failure, frailty, and resilience on heart failure and transplant outcomes*; Mezzion: Fontan Udenafil Exercise Longitudinal Assessment Trial (the FUEL-2 Study)*|None|None|None|None|None|None| |Jonathan H. Kim|Emory University School of Medicine|NIHt|None|None|None|None|None|None| |Imran Masood|Children&#x27;s Hospital of Philadelphia|None|None|None|None|None|None|None| |Seda Selamet Tierney|Lucile Packard Children&#x27;s Hospital, Stanford University Medical Center|None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be "significant" if (a) the person receives ≥$5000 during any 12-month period, or ≥5% of the person's gross income; or (b) the person owns ≥5% of the voting stock or share of the entity, or owns ≥$5000 of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest.

+Significant.

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