High-altitude environments present unique physiological challenges for athletes, particularly in endurance sports. This review synthesizes the current literature on acute and chronic adaptations to hypobaric hypoxia, which collectively influence aerobic exercise performance during competitions at very high altitude. The benefits of acclimatization for improving endurance performance are offset by risks, including altitude sickness, sleep disorders, and muscle loss, if the acclimatization strategy is not properly planned. We evaluate different strategies, highlighting their efficacy in optimizing performance while mitigating drawbacks. Nutritional interventions and psychological techniques can also affect the maintenance of physical performance at high altitudes. Despite individual variability in adaptation, gradual ascent and pre-acclimatization emerge as best practices for minimizing health risks and performance loss. The review highlights the need for tailored preparation protocols, particularly for competitions at very high altitudes, and identifies gaps in knowledge regarding preparation strategies and health effects. By integrating insights from physiology, nutrition, and psychology, this review aims to offer recommendations to help athletes and coaches navigate the complexities of adequate preparation for high-altitude sports competitions.
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