Return to Sports in Patients with Coronary Artery Disease: A Narrative Review
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Published:
Jul 26, 2026
Keywords:
Coronary Artery Disease, Cardiac Rehabilitation, Return to Sport, Quality of Life, Exercise Therapy
Main Article Content
Abstract
Introduction: Coronary artery disease (CAD) is a leading cause of mortality and morbidity, often limiting physical activity due to myocardial ischemia and ventricular dysfunction. Cardiac rehabilitation (CR) reduces cardiovascular risk, improves functional capacity, and enhances quality of life. While CR supports a safe return to sports (RTS), determining appropriate exercise intensity and type remains challenging. Guidelines from cardiology associations recommend risk assessment before RTS, often using cardiopulmonary exercise testing, but implementation varies, and research on RTS after CR in CAD patients is limited. This review explored physical activity and CR in facilitating safe RTS, addressing benefits, risks, screening, assessment, and exercise recommendations.
Methods: A literature search was conducted using PubMed, ScienceDirect, and CINAHL with keywords like “return to sport†and “coronary artery disease.†Inclusion criteria encompassed original research on RTS in CAD patients, available in full text, and focused on adults. A multi-step screening process included title, abstract, and full-text evaluations.
Results: Seventeen articles addressed the risks and benefits of physical activity in CAD patients, eleven focused on pre-participation screening and assessments, and four examined RTS recommendations. Findings were synthesized into a narrative review with tables for clarity.
Conclusion: Physical activity benefits CAD patients by improving endothelial function, autonomic balance, and plaque stability, reducing cardiovascular risk. However, high-intensity exercise may trigger acute events, necessitating pre-participation screening. Risk stratification guides safe RTS, with tailored exercise programs optimizing benefits while minimizing risks. Individualized prescriptions and periodic evaluations ensure long-term safety.
Methods: A literature search was conducted using PubMed, ScienceDirect, and CINAHL with keywords like “return to sport†and “coronary artery disease.†Inclusion criteria encompassed original research on RTS in CAD patients, available in full text, and focused on adults. A multi-step screening process included title, abstract, and full-text evaluations.
Results: Seventeen articles addressed the risks and benefits of physical activity in CAD patients, eleven focused on pre-participation screening and assessments, and four examined RTS recommendations. Findings were synthesized into a narrative review with tables for clarity.
Conclusion: Physical activity benefits CAD patients by improving endothelial function, autonomic balance, and plaque stability, reducing cardiovascular risk. However, high-intensity exercise may trigger acute events, necessitating pre-participation screening. Risk stratification guides safe RTS, with tailored exercise programs optimizing benefits while minimizing risks. Individualized prescriptions and periodic evaluations ensure long-term safety.
Article Details
How to Cite
Nazir, A., Brandon Clementius, & Hana Athaya Nurhalizah. (2026). Return to Sports in Patients with Coronary Artery Disease: A Narrative Review. Indonesian Journal of Physical Medicine and Rehabilitation, 15(01), 51 - 62. https://doi.org/10.36803/indojpmr.v15i01.471
Section
Review Article
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13. Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: the Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). Rev Esp Cardiol (Engl Ed). 2021;74(6):545.
14. Kim JH, Baggish AL, Levine BD, Ackerman MJ, Day SM, Dineen EH, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;S0735-1097(24):10722-X.
15. Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its application. Heart. 2007;93(10):1285-92.
16. Chaudhry S, Kumar N, Arena R, Verma S. The evolving role of cardiopulmonary exercise testing in ischemic heart disease–state of the art review. Curr Opin Cardiol. 2023;38(6):552-72.
17. Glaab T, Taube C. Practical guide to cardiopulmonary exercise testing in adults. Respir Res. 2022;23(1):9.
18. van Dijk WB, Schuit E, van der Graaf R, Groenwold RH, Laurijssen S, Casadei B, et al. Applicability of European Society of Cardiology guidelines according to gross national income. Eur Heart J. 2023;44(7):598-607.
19. Baldewijns K, Boyne J, de Maesschalck L, Devillé A, Brandenburg V, Brunner-La-Rocca H-P. From guideline to daily practice: Implementation of ESC-guidelines considering multidisciplinary and non-pharmacological care in heart failure in three ESC member states, a case study. JRSM Cardiovasc Dis. 2022;11:20480040221074598.
20. Borjesson M, Dellborg M, Niebauer J, LaGerche A, Schmied C, Solberg EE, et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2019;40(1):13-8.
21. Dores H, de Araújo Gonçalves P, Cardim N, Neuparth N. Coronary artery disease in athletes: An adverse effect of intense exercise? Rev Port Cardiol (Engl Ed). 2018;37(1):77-85.
22. Corrado D, Schmied C, Basso C, Borjesson M, Schiavon M, Pelliccia A, et al. Risk of sports: do we need a pre-participation screening for competitive and leisure athletes? Eur Heart J. 2011;32(8):934-44.
23. Ambrose JA, Singh M. Pathophysiology of coronary artery disease leading to acute coronary syndromes. F1000Prime Rep. 2015;7:08.
24. Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circ Res. 2014;114(12):1852-66.
25. Tucker WJ, Fegers-Wustrow I, Halle M, Haykowsky MJ, Chung EH, Kovacic JC. Exercise for primary and secondary prevention of cardiovascular disease: JACC focus seminar 1/4. J Am Coll Cardiol. 2022;80(11):1091-106.
26. Perry AS, Dooley EE, Master H, Spartano NL, Brittain EL, Pettee Gabriel K. Physical activity over the lifecourse and cardiovascular disease. Circ Res. 2023;132(12):1725-40.
27. Fernández-Rubio H, Becerro-de-Bengoa-Vallejo R, RodrÃguez-Sanz D, Calvo-Lobo C, Vicente-Campos D, Chicharro JL. Exercise training and interventions for coronary artery disease. J Cardiovasc Dev Dis. 2022;9(5):131.
28. He F, Li J, Liu Z, Chuang C-C, Yang W, Zuo L. Redox mechanism of reactive oxygen species in exercise. Front Physiol. 2016;7:486.
29. Wang F, Wang X, Liu Y, Zhang Z. Effects of exerciseâ€induced ROS on the pathophysiological functions of skeletal muscle. Oxid Med Cell Longev. 2021;2021(1):3846122.
30. Laufs U, Werner N, Link A, Endres M, Wassmann S, Jürgens K, et al. Physical training increases endothelial progenitor cells, inhibits neointima formation, and enhances angiogenesis. Circulation. 2004;109(2):220-6.
31. Börjesson M, Assanelli D, Carré F, Dugmore D, Panhuyzen-Goedkoop NM, Seiler C, et al. ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease. Eur J Cardiovasc Prev Rehabil. 2006;13(2):137-49.
32. Emery MS, Kovacs RJ. Sudden cardiac death in athletes. JACC Heart Fail. 2018;6(1):30-40.
33. Link MS. Prevention of sudden cardiac death: return to sport considerations in athletes with identified cardiovascular abnormalities. Br J Sports Med. 2009;43(9):685-9.
34. Hill SF, Sheppard MN. A silent cause of sudden cardiac death especially in sport: congenital coronary artery anomalies. Br J Sports Med. 2014;48(15):1151-6.
35. Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 2: preparticipation screening for cardiovascular disease in competitive athletes: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e267-e72.
36. Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.
37. Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(10):1451.
38. Saba MA, Goharpey S, Attarbashi Moghadam B, Salehi R, Nejatian M. Correlation between the 6-min walk test and exercise tolerance test in cardiac rehabilitation after coronary artery bypass grafting: a cross-sectional study. Cardiol Ther. 2021;10(2):201-9.
39. Staron A, AlMalki I, AlSubaie M. 2. Functional Capacity Assessment. In: Staron A, Wolszakiewicz J, AlSulaimi M, editors. Exercise Prescription in Cardiac Rehabilitation. Basel: MDPI; 2022. p. 19.
40. ACSM. ACSM’s guidelines for exercise testing and prescription 10 ed. Philadelphia: Wolters Kluwer; 2018.
41. Hsu C-J, Meierbachtol A, George SZ, Chmielewski TL. Fear of reinjury in athletes: implications for rehabilitation. Sports Health. 2017;9(2):162-7.
42. Ardern CL, Hooper N, O'Halloran P, Webster KE, Kvist J. A psychological support intervention to help injured athletes “get back in the gameâ€: design and development study. JMIR Form Res. 2022;6(8):e28851.
43. Costache A-D, Leon-Constantin M-M, Roca M, Maștaleru A, Anghel R-C, Zota I-M, et al. Cardiac biomarkers in sports cardiology. J Cardiovasc Dev Dis. 2022;9(12):453.
44. Mirabelli MH, Devine MJ, Singh J, Mendoza M. The preparticipation sports evaluation. Am Fam Physician. 2015;92(5):371-6.
2. Shahjehan RD, Sharma S, Bhutta BS. Coronary artery disease. StatPearls [Internet]: StatPearls Publishing; 2024.
3. Prabhu NV, Maiya AG, Prabhu NS. Impact of cardiac rehabilitation on functional capacity and physical activity after coronary revascularization: a scientific review. Cardiol Res Pract. 2020;2020:1236968.
4. Taylor RS, Dalal HM, McDonagh ST. The role of cardiac rehabilitation in improving cardiovascular outcomes. Nat Rev Cardiol. 2022;19(3):180-94.
5. Anderson L, Oldridge N, Thompson DR, Zwisler A-D, Rees K, Martin N, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Cochrane Database Syst Rev. 2016;67(1):CD001800.
6. Winzer EB, Woitek F, Linke A. Physical activity in the prevention and treatment of coronary artery disease. J Am Heart Assoc. 2018;7(4):e007725.
7. Brubaker PH, Ross JH, Joo KC. Contemporary approaches to prescribing exercise in coronary artery disease patients. Am J Lifestyle Med. 2016;12(2):130-9.
8. Mytinger M, Nelson RK, Zuhl M. Exercise prescription guidelines for cardiovascular disease patients in the absence of a baseline stress test. J Cardiovasc Dev Dis. 2020;7(2):15.
9. Brown TM, Pack QR, Aberegg E, Brewer LC, Ford YR, Forman DE, et al. Core components of cardiac rehabilitation programs: 2024 update: a scientific statement from the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2024;150(18):e328-e47.
10. Thompson PD. Exercise prescription and proscription for patients with coronary artery disease. Circulation. 2005;112(15):2354-63.
11. Thompson PD, Myerburg RJ, Levine BD, Udelson JE, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 8: coronary artery disease: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e310-e4.
12. Yadav Y. Exercise in the management of coronary artery disease. Med J Armed Forces India. 2007;63(4):357-61.
13. Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: the Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). Rev Esp Cardiol (Engl Ed). 2021;74(6):545.
14. Kim JH, Baggish AL, Levine BD, Ackerman MJ, Day SM, Dineen EH, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;S0735-1097(24):10722-X.
15. Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its application. Heart. 2007;93(10):1285-92.
16. Chaudhry S, Kumar N, Arena R, Verma S. The evolving role of cardiopulmonary exercise testing in ischemic heart disease–state of the art review. Curr Opin Cardiol. 2023;38(6):552-72.
17. Glaab T, Taube C. Practical guide to cardiopulmonary exercise testing in adults. Respir Res. 2022;23(1):9.
18. van Dijk WB, Schuit E, van der Graaf R, Groenwold RH, Laurijssen S, Casadei B, et al. Applicability of European Society of Cardiology guidelines according to gross national income. Eur Heart J. 2023;44(7):598-607.
19. Baldewijns K, Boyne J, de Maesschalck L, Devillé A, Brandenburg V, Brunner-La-Rocca H-P. From guideline to daily practice: Implementation of ESC-guidelines considering multidisciplinary and non-pharmacological care in heart failure in three ESC member states, a case study. JRSM Cardiovasc Dis. 2022;11:20480040221074598.
20. Borjesson M, Dellborg M, Niebauer J, LaGerche A, Schmied C, Solberg EE, et al. Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2019;40(1):13-8.
21. Dores H, de Araújo Gonçalves P, Cardim N, Neuparth N. Coronary artery disease in athletes: An adverse effect of intense exercise? Rev Port Cardiol (Engl Ed). 2018;37(1):77-85.
22. Corrado D, Schmied C, Basso C, Borjesson M, Schiavon M, Pelliccia A, et al. Risk of sports: do we need a pre-participation screening for competitive and leisure athletes? Eur Heart J. 2011;32(8):934-44.
23. Ambrose JA, Singh M. Pathophysiology of coronary artery disease leading to acute coronary syndromes. F1000Prime Rep. 2015;7:08.
24. Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circ Res. 2014;114(12):1852-66.
25. Tucker WJ, Fegers-Wustrow I, Halle M, Haykowsky MJ, Chung EH, Kovacic JC. Exercise for primary and secondary prevention of cardiovascular disease: JACC focus seminar 1/4. J Am Coll Cardiol. 2022;80(11):1091-106.
26. Perry AS, Dooley EE, Master H, Spartano NL, Brittain EL, Pettee Gabriel K. Physical activity over the lifecourse and cardiovascular disease. Circ Res. 2023;132(12):1725-40.
27. Fernández-Rubio H, Becerro-de-Bengoa-Vallejo R, RodrÃguez-Sanz D, Calvo-Lobo C, Vicente-Campos D, Chicharro JL. Exercise training and interventions for coronary artery disease. J Cardiovasc Dev Dis. 2022;9(5):131.
28. He F, Li J, Liu Z, Chuang C-C, Yang W, Zuo L. Redox mechanism of reactive oxygen species in exercise. Front Physiol. 2016;7:486.
29. Wang F, Wang X, Liu Y, Zhang Z. Effects of exerciseâ€induced ROS on the pathophysiological functions of skeletal muscle. Oxid Med Cell Longev. 2021;2021(1):3846122.
30. Laufs U, Werner N, Link A, Endres M, Wassmann S, Jürgens K, et al. Physical training increases endothelial progenitor cells, inhibits neointima formation, and enhances angiogenesis. Circulation. 2004;109(2):220-6.
31. Börjesson M, Assanelli D, Carré F, Dugmore D, Panhuyzen-Goedkoop NM, Seiler C, et al. ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease. Eur J Cardiovasc Prev Rehabil. 2006;13(2):137-49.
32. Emery MS, Kovacs RJ. Sudden cardiac death in athletes. JACC Heart Fail. 2018;6(1):30-40.
33. Link MS. Prevention of sudden cardiac death: return to sport considerations in athletes with identified cardiovascular abnormalities. Br J Sports Med. 2009;43(9):685-9.
34. Hill SF, Sheppard MN. A silent cause of sudden cardiac death especially in sport: congenital coronary artery anomalies. Br J Sports Med. 2014;48(15):1151-6.
35. Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 2: preparticipation screening for cardiovascular disease in competitive athletes: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e267-e72.
36. Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.
37. Ross RM. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(10):1451.
38. Saba MA, Goharpey S, Attarbashi Moghadam B, Salehi R, Nejatian M. Correlation between the 6-min walk test and exercise tolerance test in cardiac rehabilitation after coronary artery bypass grafting: a cross-sectional study. Cardiol Ther. 2021;10(2):201-9.
39. Staron A, AlMalki I, AlSubaie M. 2. Functional Capacity Assessment. In: Staron A, Wolszakiewicz J, AlSulaimi M, editors. Exercise Prescription in Cardiac Rehabilitation. Basel: MDPI; 2022. p. 19.
40. ACSM. ACSM’s guidelines for exercise testing and prescription 10 ed. Philadelphia: Wolters Kluwer; 2018.
41. Hsu C-J, Meierbachtol A, George SZ, Chmielewski TL. Fear of reinjury in athletes: implications for rehabilitation. Sports Health. 2017;9(2):162-7.
42. Ardern CL, Hooper N, O'Halloran P, Webster KE, Kvist J. A psychological support intervention to help injured athletes “get back in the gameâ€: design and development study. JMIR Form Res. 2022;6(8):e28851.
43. Costache A-D, Leon-Constantin M-M, Roca M, Maștaleru A, Anghel R-C, Zota I-M, et al. Cardiac biomarkers in sports cardiology. J Cardiovasc Dev Dis. 2022;9(12):453.
44. Mirabelli MH, Devine MJ, Singh J, Mendoza M. The preparticipation sports evaluation. Am Fam Physician. 2015;92(5):371-6.