D’Ascenzi F (Chair); Sanz-de la Garza M (Co-chair); Many International Centres
Maestrini V; Cameli M; et al

European heart journal cardiovascular Imaging. 27(8):1449-1468, 2026 Jul 31.

Exercise imaging, particularly exercise stress echocardiography (ESE), has
become a pivotal non-invasive tool for evaluating cardiovascular function
in athletes and for distinguishing physiological adaptations from
pathological conditions. This Clinical Consensus Statement by the European
Association of Preventive Cardiology and the European Association of
Cardiovascular Imaging synthesizes current evidence and provides practical
guidance on indications, protocols, and interpretation of exercise imaging
modalities in both competitive and recreational athletes. The document
emphasizes the role of ESE in assessing cardiac reserve, unmasking
concealed cardiomyopathies, and stratifying risk in clinical scenarios
such as T-wave inversion, exercise-induced repolarization abnormalities,
and extreme ventricular remodelling. Special attention is given to imaging
protocols tailored to the athletic population, including dynamic
assessment of the right and left ventricles, atria, and valvular function
during various exercise modalities, highlighting the importance of the
functional evaluation in athletes and active individuals. Additionally,
the consensus explores the integration of advanced techniques such as
cardiopulmonary exercise testing and exercise cardiac magnetic resonance
imaging, highlighting their complementary roles in comprehensive
cardiovascular evaluation. The statement advocates for individualized
testing strategies that consider sport-specific demands, demographic
factors such as body size, sex, ethnicity, and the underlying pathology.
It also underscores the importance of exercise imaging in guiding sports
eligibility and in tailoring exercise prescription for competitive
athletes, as well as for patients willing to participate in recreational
sports or exercise programs. Copyright This article has been co-published
with permission in the European Journal of Preventive Cardiology and the
European Heart Journal – Cardiovascular Imaging. All rights reserved.
The European Society of Cardiology 2026. The articles are identical
except for minor stylistic and spelling differences in keeping with each
journal’s style. Either citation can be used when citing this article.