Management of mature athletes with cardiovascular conditions

### Learning objectives Exercise is a potent therapy for the prevention1–4 and rehabilitation5 of cardiovascular disease, including the management of risk factors for atherosclerotic cardiovascular disease.6 It is important to recognise, however, that an ‘exercise paradox’ exists where vigorous physical activity transiently elevates the risk of sudden cardiac death (SCD) (figure 1). The risk is greatest in individuals who are not accustomed to regular exercise and undertake high intensity physical activity with little or no systematic training.7–9 Figure 1 Exercise paradox. AF, atrial fibrillation; SCD, sudden cardiac death. Data taken from Nocon et al ,1 Warburton et al ,6 Marijon et al ,17 Moore et al ,2 McTiernan et al 3 and Hamer et al .4 In a previous review in the journal, we outlined the management of young competitive athletes with cardiovascular conditions.10 This population has been the main focus of attention for preparticipation screening,11 12 as the early detection of inherited cardiomyopathies and arrhythmic syndromes has the potential to prevent decades of lost life. Though widely debated,13 the methods of screening in this population are generally acceptable, and particularly the inclusion of an ECG is effective in detecting the majority of potentially fatal cardiac conditions relevant to this population.14 15 SCDs among young competitive athletes, however, account for just over 6% of all exercise-related SCDs.16 A far greater burden falls to non-elite, older athletes over 35 years of age, where the cause is overwhelmingly due to coronary artery disease …