Physical activity and competitive sport safety for children affected by inherited cardiac conditions and selected acquired cardiomyopathies: emerging evidence and areas for further inquiry

Abstract Physicians tasked with caring for children with inherited cardiac conditions (ICCs) face complex decisions regarding safe participation in physical activity and competitive sport. Historically, concerns over sudden cardiac death (SCD) and disease progression led to widespread exercise restrictions. However, emerging evidence and evolving guidelines now support a more nuanced, risk-based approach. This narrative review explores current recommendations for exercise in children with major ICCs—including channelopathies, cardiomyopathies, and aortopathies. It highlights advances in risk stratification, the use of exercise testing, cardiac imaging, and genetic information to guide individualised recommendations. Shared decision-making (SDM) is emphasised as central to balancing arrhythmic and disease progression risk with the substantial physical, psychological, and social benefits of exercise. The review also discusses non-inherited conditions like anthracycline-induced cardiomyopathy and myocarditis. Despite progress, substantial variation exists in international guidelines, and there remains a paucity of paediatric-specific data. This poses a significant challenge and often necessitates utilising adult data when making decisions for children. Conclusion : Further research, including registries and multi-centre studies, is essential to improve evidence-based recommendations and empower clinicians, patients, and families in decision-making. A personalised approach—grounded in expertise, communication, and longitudinal follow-up—is critical to safely supporting children with ICCs in leading active, fulfilling lives. What is Known: • Inherited cardiac conditions (ICCs) are associated with ventricular arrhythmia, heart failure, and sudden cardiac death (SCD) prompting caution around sports and physical activity. • Myocarditis and anthracycline-induced cardiomyopathy are common aetiologies of cardiac dysfunction. What is New: • Observational studies in paediatric cohorts are reassuring for continued participation in sports following guideline-directed shared decision-making. • Cardiac rehabilitation improves left ventricular function in paediatric cancer survivors. Graphical Abstract