While physical activity is recommended for patients with heart disease who have a pacemaker or an implantable cardioverter-defibrillator (ICD), it requires choosing the right device and programming to prevent inappropriate shocks, Christophe Vô, MD, pediatric cardiologist at Saint-Luc University Clinic, Brussels, Belgium, reminded attendees at the European Days of the French Society of Cardiology (JESFC 2026) held on January 14-16, 2026.

“We are starting to take the patient’s physical activity into account when deciding whether to implant a pacemaker. We consider the type of pacemaker or ICD to implant based on the sport practiced and the best site for implantation. For example, in a left‑handed patient, we will avoid placing the device on the left side,” Vô said.

To choose the most appropriate device, “you have to assess the patient’s sporting habits or the expectations of younger patients in terms of physical activity” even before implanting an ICD or pacemaker. Some devices, for example, are equipped with algorithms and sensors that better detect heart‑rate changes related to physical activity.

Optimizing Response

Programming must consider the physical activity as well as the underlying heart condition after evaluating arrhythmia risk using an ECG and an exercise stress test. It is important to optimize the device’s response to exercise, set appropriate monitoring frequency limits, and clearly define the arrhythmia detection zones.

With this personalized programming, it is important to determine the maximum heart rate the patient can reach and inform them that exceeding that rate may place them in the arrhythmia detection zone and trigger the device.

Adult congenital heart disease is the most common congenital abnormality. Whereas deaths formerly occurred early, more than 80% of affected children now reach adulthood. “This is a young population that may be seeking regular physical activity, even competition,” Vô said.

In these patients, the benefits of physical activity are well demonstrated, both physiologically and psychologically. Besides improving self‑esteem and promoting social ties, exercise reduces the risk for physical deconditioning, increases functional capacity, and can even improve cardiac output in some heart conditions.

However, in this higher‑risk population for arrhythmia, nearly 10% have an ICD or a pacemaker. The risk for bradyarrhythmia or tachyarrhythmia depends on the heart condition. Overall, the more complex the heart disease, the greater the arrhythmia risk.

Activity Sensor

So, how do you adapt sports activities and the implanted device? It depends on the type of stimulation. For example, in atrioventricular block, the device’s role is to stimulate the ventricle after atrial stimulation. During physical activity, the pacemaker needs to pace at higher frequencies. However, the device is programmed by default with low frequencies, explained Vô.

In patients with atrioventricular block, programming expertise is required to adapt the pacemaker to physical activity before implantation. Depending on age and the sport practiced, it may be necessary to reach 160-180 beats/min, especially in younger patients. Only certain models can go above 180 beats/min.

For a pacemaker to be able to pace at high frequencies, the interval between atrial sensing and ventricular pacing — and the device’s refractory period — must both be shortened. If this is not considered, high rates can lead the pacemaker to generate a 2:1 block — a sudden halving of the ventricular rate under heavy exertion.

Another example: in sinus node dysfunction, the choice of pacemaker depends on the integrated sensor that allows the heart rate to increase in response to detected effort. Most often, this is a motion sensor (accelerometer) that measures upper‑body acceleration. Other pacemakers can estimate effort by analyzing respiration or cardiac contraction.

Assessing Arrhythmia Risk

These sensors are generally poorly suited to static exercises or intermittent sports that alternate between static and more physical activity. A pacemaker with an accelerometer is ideal for activities such as running or hiking, but is not well suited to cycling.

For cycling or static activity, patients with a pacemaker equipped with a motion sensor are advised to move their upper body to activate the device, Gilles Bosser, MD, University Hospital of Nancy, France, said at the end of the presentation during a Q&A session. This advice also applies before a strenuous activity.

Only Biotronik devices are equipped with sensors that assess changes in impedance after myocardial contraction to adapt heart rate. In sinus node dysfunction, this is probably the most physiologically appropriate stimulation. The device can thus more easily detect static activity.

With an ICD, there is a risk for inappropriate shocks if the rate detection zones have been poorly set. Inappropriate shocks can occur even when the patient is engaged in physical activity that increases their heart rate up to the detection zone.

In this context, the stress test is important to evaluate the device’s response. “It also helps determine the arrhythmia detection zones that will trigger defibrillation and the refractory‑period zones that can cause a 2:1 block from a pacemaker.”

Contact Sports to Avoid

The risk for arrhythmia also depends on the type of heart disease, as well as surgical procedures, which increase or decrease the risk for ventricular arrhythmias depending on scarring. Some arrhythmias can also be linked to surgical complications, such as coronary artery damage. 

To determine this risk and adapt the cardiac device accordingly, clinicians should rely on the exercise stress test and ECG, as well as Holter monitoring and electrophysiological study, to record continuous heart activity. Clinicians should not hesitate to use these tools to determine arrhythmia risk.

Finally, the device’s implantation site is important. If the patient wants to practice a one‑sided sport, like tennis or badminton, the stimulator should be implanted on the nondominant side. In contact sports, it can also be useful to wear a pad over the device for protection.

As a reminder, patients are advised to wait 6 weeks after implantation before resuming sports, Vô said. Except for combat sports, all sports can be practiced.

This story was translated from Medscape's French edition.