What are the guidelines for individuals with a patent foramen ovale (PFO) participating in sports?

PFO and Sports Participation

Individuals with an isolated patent foramen ovale (PFO) can participate in all competitive sports without restriction. 1

General Sports Participation Guidelines

• Athletes with PFO require no sports restrictions unless they have associated complications such as pulmonary hypertension, right-to-left shunting with congenital defects, or right ventricular dysfunction. 1

• Routine screening for PFO should NOT be performed for athletes participating in recreational scuba diving or free diving. 1

• The 2025 American Heart Association/American College of Cardiology guidelines explicitly state that PFO presence alone is not a contraindication to any level of sports participation, including high-intensity competitive athletics. 1

• The 2005 European Society of Cardiology consensus document confirms that athletes with small or closed ASD and PFO can participate in all sports with yearly follow-up, provided there is no significant arrhythmia, ventricular dysfunction, or pulmonary hypertension. 1

Specific High-Risk Environment Considerations

High-Altitude Activities

• Athletes with isolated PFO can safely participate in high-altitude training and competition (>2500 meters). 1

• However, athletes with pulmonary arterial hypertension (mean PA pressure >25 mmHg) or congenital defects with right-to-left shunting may be at elevated risk and require clinical evaluation before high-altitude activities. 1

Scuba and Free Diving

• PFO is NOT a contraindication to recreational scuba diving. 1

• Divers found to have a PFO should be counseled on routine measures to reduce the risk of embolic complications from decompression illness, but diving restrictions are not mandated. 1

• Routine cardiac screening for PFO should not be performed in recreational scuba and free divers. 1

• Shared decision-making should incorporate the additional risks that underwater cardiovascular events pose to the diver and other dive team members. 1

Sports Physical Clearance Algorithm

For the standard sports physical examination:

1. No additional cardiac testing is required beyond standard history and physical examination for asymptomatic athletes with known PFO. 1

2. Clearance for all sports should be granted if the athlete has:

   • No symptoms of breathlessness or exercise intolerance 1
   • No pulmonary hypertension 1
   • No right ventricular dysfunction 1
   • No significant arrhythmias 1

3. Annual follow-up is reasonable for athletes with known PFO to monitor for development of complications, though this is based on older European guidance. 1

Critical Pitfalls to Avoid

• Do not confuse PFO with hemodynamically significant atrial septal defect (ASD). Large ASDs (>6mm) require different management and may necessitate sports restrictions until closure. 1

• Do not restrict sports participation based solely on PFO diagnosis in the absence of associated cardiopulmonary complications. This represents unnecessary limitation without evidence-based justification. 1

• Do not perform routine PFO screening in asymptomatic athletes, as the presence of PFO does not change sports eligibility and may lead to unnecessary anxiety and interventions. 1

• Recognize that prior cryptogenic stroke with PFO represents a different clinical scenario requiring neurologic and cardiac consultation, but even in these cases, return to sports after appropriate evaluation and treatment (medical therapy or closure) is often feasible. 1, 2