Defying the odds: Why athletes with hypertrophic cardiomyopathy can still be competitive

Recent advancements in medical understanding mean that athletes with HCM can safely compete.

Hypertrophic cardiomyopathy (HCM) is a genetic condition characterised by the thickening of the heart muscle, which can impede normal heart function and increase the risk of arrhythmias and sudden cardiac arrest. Historically, the diagnosis of HCM has often meant an immediate halt to an athlete’s career, with the presumption that intense physical activity exacerbates the risks associated with the condition. However, recent advancements in medical understanding and technology suggest that, under proper management and monitoring, athletes with HCM can safely continue to compete.

Advances in understanding HCM

Recent studies have provided deeper insights into HCM, revealing that the condition is not as uniformly dangerous as once thought. The severity of HCM varies widely among individuals, with some experiencing minimal symptoms and others facing significant challenges. This variability underscores the importance of personalised medicine in managing HCM, where each athlete's unique condition is assessed rather than imposing a blanket prohibition.

Improved screening and monitoring

Technological advancements have significantly improved the screening and monitoring of athletes with HCM. Sophisticated imaging techniques, such as cardiac MRI and echocardiography, allow for detailed assessments of heart structure and function. Wearable technology enables continuous monitoring of heart rhythms, providing real-time data that can alert athletes and medical teams to potential issues before they become life-threatening. These tools collectively enhance the safety net for athletes with HCM, allowing for early intervention and tailored management strategies.

Individualised risk assessment

The concept of individualised risk assessment is gaining traction in sports cardiology. Athletes with HCM can undergo comprehensive evaluations to determine their specific risk profile. This includes genetic testing, family history analysis, and exercise testing to understand how their heart responds to physical stress. Such assessments can identify those at higher risk and tailor recommendations, accordingly, potentially allowing those with lower risk to continue competing under careful supervision.

Benefits of physical activity

Physical activity has well-documented benefits for cardiovascular health, including improved heart function, reduced blood pressure, and enhanced overall well-being. For athletes with HCM, maintaining an active lifestyle can have psychological and physical benefits that outweigh the risks, provided their condition is well-managed. Exercise can contribute to better heart health, which, paradoxically, might mitigate some of the risks associated with HCM.

Case for competitive sports

Competing in sports provides more than physical benefits; it fosters mental resilience, social connections, and a sense of purpose. For many athletes, their identity and emotional well-being are closely tied to their sport. Denying them the opportunity to compete can have profound negative impacts on their mental health. With appropriate precautions, these athletes can enjoy the benefits of sports while minimising the risks.

Implementing safe competition protocols

To allow athletes with HCM to compete safely, a comprehensive approach is essential. This includes:

Regular medical check-ups: Frequent assessments by a cardiologist experienced in sports medicine to monitor the athlete’s heart condition and adjust management plans as needed.

Customised training programs: Tailored exercise regimens that take into account the individual’s condition, focusing on safe intensity levels and avoiding activities that could trigger adverse events.

Emergency preparedness: Ensuring that sporting events are equipped with automated external defibrillators (AEDs) and that staff are trained in emergency response protocols.

Informed decision-making: Educating athletes and their families about the risks and benefits, empowering them to make informed decisions about their participation in sports.

Conclusion

The landscape of HCM management in athletes is evolving, driven by improved medical knowledge and technology. While caution is necessary, the potential for athletes with HCM to safely compete underlines the importance of individualised care and comprehensive management. Allowing these athletes to continue their sporting pursuits not only respects their autonomy but also acknowledges the significant physical, mental, and social benefits of athletic participation.

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Frequently Asked Questions (FAQs)

Defying the odds: Why athletes with hypertrophic cardiomyopathy can still be competitive

Q. Were athletes with hypertrophic cardiomyopathy always excluded from competition?
A: Historically, yes. HCM was long considered a high-risk condition for sudden cardiac death, leading to blanket exclusion from competitive sport based largely on early observational data. 

Q. What has changed in recent thinking about HCM and sport participation?
A: More recent evidence suggests the risks may be lower than previously thought, prompting a shift away from universal restriction toward more individualised assessment and participation decisions. 

Q. Is it now considered safe for some athletes with HCM to compete?
A: In selected cases, yes. Studies indicate that athletes engaging in vigorous exercise do not necessarily have higher rates of adverse events, supporting carefully supervised participation. 

Q. What role does shared decision-making play in these decisions?
A: Shared decision-making is now central, with clinicians and athletes jointly considering risks, sport demands, and personal goals rather than applying automatic disqualification. 

Q. Why is there still debate about allowing athletes with HCM to compete?
A: Despite evolving evidence, HCM still carries a risk of serious cardiac events, and uncertainties remain. Balancing safety, autonomy, and quality of life continues to make this a complex and contested issue.

Q. How should clinicians approach return-to-play decisions in athletes with hypertrophic cardiomyopathy?
A: Decisions should be individualised, incorporating risk stratification, symptom profile, imaging findings, and the athlete’s goals, with a structured shared decision-making process.

Q. What factors increase risk in athletes with HCM?
A: Key risk factors include prior syncope, family history of sudden cardiac death, significant left ventricular hypertrophy, ventricular arrhythmias, and evidence of myocardial fibrosis.

Q. How should clinicians counsel athletes about participation risks?
A: Counselling should clearly outline known risks and uncertainties, emphasising that while some athletes may safely participate, HCM remains associated with potentially serious cardiac events.

Q. What monitoring is recommended for athletes with HCM who continue to compete?
A: Ongoing follow-up should include regular clinical review, imaging, and rhythm monitoring, with reassessment of risk over time and adjustment of activity recommendations as needed.

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References

Chan, F, Lockie, T, Monserrat, L. et al. Subclinical Hypertrophic Cardiomyopathy in Elite Athletes: Knowledge Gaps Persist. J Am Coll Cardiol Case Rep. 2022 Jan, 4 (2) 94-98.  https://doi.org/10.1016/j.jaccas.2021.11.004

Semsarian, C, Gray, B, Haugaa, K. et al. (2022). Athletic activity for patients with hypertrophic cardiomyopathy and other inherited cardiovascular diseases: JACC Focus Seminar 3/4. Journal of the American College of Cardiology, 80(13): 1268-1283.https://doi.org/10.1016/j.jacc.2022.07.013

Elena Arbelo E et al. (2023). 2023 ESC Guidelines for the management of cardiomyopathies: Developed by the task force on the management of cardiomyopathies of the European Society of Cardiology (ESC), European Heart Journal, 44(37): 3503-3626. https://doi.org/10.1093/eurheartj/ehad194

Malhotra A, Sharma S. (2017). Hypertrophic cardiomyopathy in athletes. European Cardiology Review, 12(2):80-82. doi: 10.15420/ecr.2017:12:1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223355/

McKinney J et al. (2024). New insights and recommendations for athletes with hypertrophic cardiomyopathy. Canadian Journal of Cardiology, 40(5): 921-933. https://onlinecjc.ca/article/S0828-282X(24)00162-4/abstract

Sheikh N, et al. (2015). Clinical profile of athletes with hypertrophic cardiomyopathy. Circulation: Cardiovascular Imaging, 8(7): https://www.ahajournals.org/doi/full/10.1161/CIRCIMAGING.114.003454

Snir AW et al. (2021). Exercise in hypertrophic cardiomyopathy: restrict or rethink. American Journal of Physiology - Heart and Circulatory Physiology, 320(5): H2101-H2111. https://journals.physiology.org/doi/full/10.1152/ajpheart.00850.2020