A paradigm shift has evolved regarding the return to sport for diagnosed competitive athletes.
Hypertrophic cardiomyopathy often goes undiagnosed because many people with it have few symptoms.
The diagnosis of a life-threatening cardiovascular disease such as hypertrophic cardiomyopathy (HCM) in a young athlete presents a complex dilemma in terms of athlete safety, patient autonomy, team risk tolerance, and medical decision-making .
Previously, medical advice supported the “blanket” disqualification of athletes with HCM from competitive sport.
Recently, however, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports of older athletes with HCM who continue to exercise have fueled debate about whether it is safe to initiate sports activity with a diagnosis of HCM.
Shared clinical decision making is supported within the sports cardiology community where athletes can make an informed decision about treatment options and potentially choose to continue competitive sports participation.
HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM.
Shared clinical decision making in sports cardiology
Shared decision making is a collaborative process between the patient, other stakeholders (eg, parents), and the physician that combines the principles of informed consent and patient autonomy.
A shared decision-making approach considers the patient’s values and preferences and is especially important when more than one option in clinical management is reasonable.
Within sports cardiology eligibility decisions, all stakeholders with an interest in the outcome are involved in the decision process with the consent of the patient (or parents of children), including family members, sports trainers, physical therapists, medical team officials, cardiologists, coaches and team, school or club officials.
A careful discussion of the potential harms and benefits of different treatment options, including continued participation in competitive sports, should be explored using the best available evidence. Ideally, the final decision should be acceptable to all parties.
A paradigm shift has evolved regarding the return to sport for competitive athletes diagnosed with cardiovascular disease.
Criteria that once led to universal sports disqualification are now being considered for replay on a case-by-case basis. Shared decision making in sports cardiology was first highlighted in young individuals with long QT syndrome (LQTS). Two observational studies reported that young athletes with genotype-positive LQTS who underwent appropriate counseling, optimal medical management, and adherence to treatment could return to sport with a low rate of ACS and no increased mortality.
Precisely regarding the periodic screening of these patients, Dr. Edmundo Jordán, a cardiologist and past president of the Puerto Rican Society of Cardiology, maintained that the key to this population is that it be diagnosed on time, but above all, that they have a rigorous evaluation together with your cardiologist.
“This entity can develop a cardiomyopathy, because the heart muscle grows into the cavity, specifically in the septum, and does not allow an adequate flow of blood volume movement and the patient will have symptoms such as shortness of breath, chest pain , especially when the patient is exercising. That is why athletes are screened with an electrocardiogram, where it is evaluated if they have a hypertrophic cavity, because it is associated with the overgrowth of the left ventricular chamber (LVOT). Here comes the see a cardiologist,” he said, referring to the medical term hypercontractility of the heart muscle.
He added that precisely cardiologists suspect this condition when they hear cases of healthy patients who, practicing sports, suddenly collapse.
“Precisely when we know that an athlete collapses, the first thing we think of is hypertrophic cardiomyopathy, as it is an event that occurs suddenly in patients who we understand to be healthy. If the patient has a defibrillator nearby, we can bring him back. Follow-up should be a close one, and risk classification stratification. As there is an overgrowth of the septum, the larger the cavity, the greater the risk of sudden death. Many of these patients we do not allow discharge exercises intensity and the athlete is eliminated from high performance sports activity”, he reiterated.
However, mitigating the risk of other cardiovascular diseases that affect young athletes may not be possible. For example, data indicate that vigorous exercise increases the risk of ventricular arrhythmias and disease progression in patients with arrhythmogenic cardiomyopathy.
Indeed, recommendations against competitive sports for patients diagnosed with arrhythmogenic cardiomyopathy remain universally supported by sports cardiology experts. Therefore, patient autonomy regarding sports participation is not absolute, and shared decision making should not be oversimplified as a process where the athlete simply makes the decision.
Is exercise beneficial in patients with HCM?
Recent studies have shown that exercise is beneficial for older patients with HCM. The “Exploratory Study of Exercise Training in Hypertrophic Cardiomyopathy” randomized trial established that 16 weeks of moderate-intensity exercise resulted in a small but significant increase in exercise capacity in older adult patients (mean age 50.4 years) with HCM. . These slight increases in cardiorespiratory fitness may be associated with reductions in cardiovascular mortality.
Similarly, a retrospective survey of adult HCM patients (mean age 49 years) suggested that lifelong vigorous exercise correlated with favorable diastolic function and was not associated with ventricular arrhythmias.
A supervised cardiac rehabilitation exercise program in symptomatic patients with HCM (mean age 62±13 years) also demonstrated improved functional capacity. While these studies inform activity recommendations for older HCM patients, they were not designed to establish safety in adolescent and young adult competitive athletes where disease course and exercise intensity may be profoundly different.