Exercise in cardiomyopathies: updated evaluation, risk stratification, and clinical prescription.

Cardiomyopathies comprise a heterogeneous group of myocardial disorders that may increase the risk of potentially life-threatening arrhythmias, particularly during physical activity. Historically, this risk prompted conservative recommendations, often leading to broad restrictions on exercise participation. However, advances in the understanding of pathophysiological mechanisms, coupled with improved tools for phenotypic assessment, risk stratification, and genetic evaluation, have enabled a more nuanced and individualized approach. This narrative review provides an updated overview of the relationship between exercise and cardiomyopathies, emphasizing clinical, functional, and imaging markers associated with elevated arrhythmic risk. It also summarizes key criteria that guide decisionmaking regarding which patients may safely engage in low-, moderate-, or even high-intensity physical activity. The importance of comprehensive clinical evaluation, shared decision-making, and longitudinal follow-up is highlighted, as these elements allow exercise prescriptions to be tailored to the specific characteristics and evolving risk profile of each patient. Based on current evidence, exercise should no longer be viewed as a universal contraindication; instead, it may serve as a therapeutic adjunct in appropriately selected and well-stratified individuals.