Hypertrophic cardiomyopathy: changing the paradigm of exercise prescription and competitive sport participation

Historically, individuals with hypertrophic cardiomyopathy (HCM) have been systematically excluded from vigorous exercise and competitive sports due to concerns about increased sudden cardiac death (SCD) risk. However, emerging evidence has challenged this paradigm. Observational studies and randomized trials demonstrate improvements in functional capacity, quality of life, and overall cardiovascular and psychological health with tailored exercise in HCM populations -including competitive sports in low-risk individuals-in the absence of safety signals. Low-risk individuals are defined by the lack of well-established adverse features such as a high European Society of Cardiology HCM SCD risk score, exercise-induced syncope, severe left ventricular outflow tract obstruction and ventricular arrhythmias. The concept that this low-risk subset can safely engage in competitive sports is becoming widely accepted internationally, although local differences exist in terms of regulations and clinical approaches. For individuals who do not meet low-risk criteria, evidence is more limited. Nevertheless, participation in competitive sports may still be considered on an individual basis, after appropriate risk mitigation strategies (including treatment of obstruction and ICD implantation when indicated). A contemporary approach to HCM should be based on individualized, goal-oriented exercise prescription, supported by multidisciplinary counselling and shared decision-making, recognizing the importance of aligning medical recommendations with individual safety, values, goals, and quality of life. In this review, we critically appraise the emerging evidence surrounding vigorous exercise and competitive sports in HCM and explore how novel data are reshaping clinical practice and international guidelines, setting the stage for a paradigm in the field.