Exercise Restrictions and Suggestions for Hypertrophic Cardiomyopathy

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Hypertrophic cardiomyopathy (HCM) is one of the cardiac conditions associated with sudden death in young athletes

HCM is one of the more common genetic cardiac disorders, affecting 1 in every 500 people.Furthermore, more than half of the sudden deaths that are caused by HCM occur in African Americans.

Anyone who has HCM needs to know about the risk of sudden death, and must be aware of the risk exercise poses to people who have this condition.

What Is Hypertrophic Cardiomyopathy?

HCM is a cardiac condition characterized by an abnormal thickening of the heart muscle, a condition called hypertrophy. The hypertrophy can cause several problems. It produces an excessive "stiffness" in the left ventricle of the heart. It can also cause a partial obstruction to blood flow in the left ventricle, producing a condition similar to aortic stenosis. HCM is also associated with abnormal function of the mitral valve.

These features of HCM can lead to diastolic dysfunction and diastolic heart failure, or to dilated cardiomyopathy and the more “typical” variety of heart failure. It can also cause mitral regurgitation, which itself can cause or worsen heart failure.

But the most dreaded consequence of HCM is that it can make the heart muscle prone to develop ventricular tachycardia and ventricular fibrillation—arrhythmias that may produce sudden death. While these arrhythmias can occur at any time, they are most likely to occur during periods of vigorous exercise.

Young boys playing soccer

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Unfortunately, sudden death may be the very first manifestation of HCM, especially in young athletes. Routine screening with an ECG, or better yet, an echocardiogram, would uncover the problem in most athletes before a life-threatening event. But given the millions of young athletes who participate in sports worldwide, such routine screening generally has been deemed cost prohibitive.

Nonetheless, any young athlete who has had a family member die suddenly, or who has a family history of HCM, needs to be screened for this condition. And if HCM is diagnosed, he or she should follow accepted exercise recommendations for young athletes with HCM.

Hypertrophic Cardiomyopathy Symptoms

The symptoms of HCM don't always manifest from an early age and some people may not have any symptoms at all. Usually, symptoms develop around adolescence or puberty and tend to worsen over time.

A person with HCM may have:

  • Fatigue
  • Arrhythmias
  • Dizziness
  • Lightheadedness
  • Fainting or near fainting (syncope)
  • Heart palpitations
  • Swelling in the ankles, feet, legs, abdomen, or neck veins
  • Chest pain or shortness of breath, especially during physical activities

How Is Exercise Related to Risk?

The risk of sudden death with HCM is higher during exercise than at rest. Furthermore, the risk caused by exercise appears to be related to the intensity of exercise and even the intensity of training.

In particular, highly dynamic sports including basketball, football and swimming, are associated with higher risk than less intensive sports, and that athletes in highly competitive programs (Division I as compared to Division 2 or Division 3 collegiate athletic programs) are at higher risk.

It is clear that not everyone with HCM shares the same level of risk. Some people with HCM have sudden death at rest or during mild exertion, while others with HCM participate in extremely competitive, high-intensity sporting events for years without having life-threatening cardiac arrhythmias.

Predicting an Individual's Risk

Everyone with HCM should undergo some testing to see what their individual risk of sudden cardiac arrest might be. Testing should also determine whether they might benefit from an implanted cardiac defibrillator (ICD).

In addition to a history and physical examination, an echocardiogram should be performed to assess the degree of left ventricular thickening, the degree of left ventricular outflow obstruction, and to assess any mitral valve dysfunction.

Doctors may also order exercise stress testing to look for a normal blood pressure response (that is, an increase in blood pressure with increasing exercise levels), and to see whether there are any exercise-induced cardiac arrhythmias.

General Exercise Recommendations for Young Athletes With HCM

Given the variability in risk, and a limited ability to assign a specific risk level to a specific individual, recommendations on exercise recommendations for young athletes need to be individualized, and a fully transparent shared decision-making process should be employed.

General guidelines, published in 2019 by the European Association of Preventive Cardiology, recommend attempting to assign the young athlete with HCM either to a higher-risk group or a lower-risk group. This assignment should be made after a complete medical evaluation.

The higher-risk group, in which exercise is not recommended, includes anyone who has had any of the following:

  • A history of cardiac arrest
  • Symptoms suggesting a serious cardiac arrhythmia, especially syncope
  • Cardiac dysfunction attributable to HCM
  • Significant left ventricular outflow obstruction
  • Abnormal blood pressure response to exercise

Adults without these features can be selectively allowed to participate in competitive sports, except sports where the occurrence of syncope could lead to serious injury or death. This decision should be made with full awareness that, despite being assigned to the lower-risk group, the risk of exercise with HCM is still higher than normal.

However, the latest U.S. guidelines recommend all athletes with HCM participate only in low-intensity (1A) sports such as golf, bowling, or yoga. Both groups emphasize the need for thoughtful discussion and shared decision making involving the athlete-patient, doctor, and parent (if applicable).

A Word From Verywell

If there is a history of HCM or unexplained sudden death in your family, it's important for all family members to be evaluated for the condition, sooner rather than later. This is especially the case for any young athletes in the family, considering the prevalence of sudden death occurring during exercise. With an early diagnosis, supervised exercise, and routine monitoring, people with HCM can live long, fulfilling lives.

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  2. Burns J, Jean-Pierre P. Disparities in the diagnosis of hypertrophic obstructive cardiomyopathy: A narrative review of current literature. Cardiol Res Pract. 2018 Oct;1(1):1-6. doi:10.1155/2018/3750879

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