Abstract
Cardiomyopathies, including hypertrophic (HCM), dilated (DCM), and arrhythmogenic (ACM) forms, represent a challenge in cardiovascular medicine, in particular regarding exercise participation and cardiac rehabilitation. Traditionally, physical activity was restricted in these patients due to concerns over arrhythmic risk and sudden cardiac death. However, current evidence suggests that individualized exercise programs, under clinical supervision, can enhance functional capacity, improve quality of life, and sometimes prognosis in selected patients. Contemporary European and North American guidelines suggest that participation in competitive sports may be reasonable for athletes with genetic cardiomyopathies, provided that individual risk is regularly and systematically reassessed. The aim of this review is to synthetize current evidence on exercise training, sports participation and rehabilitation in the three major cardiomyopathies-hypertrophic, dilated, and arrhythmogenic-which have informed the latest international guideline recommendations. Particular attention is given to the essential role of shared decision-making, highlighting the importance of a personalized approach based on the specific type of cardiomyopathy, arrhythmic risk stratification, and individual patient factors. In addition, the review addresses two emerging clinical scenarios: sports participation in patients with implantable cardioverter-defibrillators and current recommendations for genotype-positive/phenotype-negative individuals at risk of cardiomyopathy.