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Original Investigation
May 17, 2023

Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy

Author Affiliations
  • 1Department of Medicine, Yale School of Medicine, New Haven, Connecticut
  • 2Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
  • 3Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
  • 4Department of Molecular Pharmacology & Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
  • 5Department of Pediatric Cardiology, Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, Ohio
  • 6Lurie Children’s Hospital, Chicago, Illinois
  • 7College of Health Solutions, Arizona State University, Tempe
  • 8Hypertrophic Cardiomyopathy Association, Denville, New Jersey
  • 9St George’s Hospital NHS Foundation Trust/St George’s University of London, London, United Kingdom
  • 10Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
  • 11Department of Medicine, Johns Hopkins University, Baltimore, Maryland
  • 12Department of Pediatrics, Oregon Health and Science University, Portland
  • 13Division of Cardiology, Children’s National Hospital, Washington, DC
  • 14Department of Pediatrics, George Washington University School of Medicine, Washington, DC
  • 15Division of Cardiology, PIH Health Good Samaritan Hospital, Los Angeles, California
  • 16Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 17Department of Internal Medicine, University of Michigan, Ann Arbor
  • 18Department of Cardiology, Liverpool Heart and Chest Hospital/Liverpool John Moores University, Liverpool, United Kingdom
  • 19Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
  • 20Department of Pediatrics, Stanford School of Medicine, Stanford, California
  • 21Yale Center for Analytic Sciences, Yale School of Medicine, New Haven, Connecticut
  • 22Department of Cardiology, Mayo Clinic, Rochester, Minnesota
  • 23Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
  • 24Department of Cardiovascular Medicine, Cleveland Clinic Heart, Vascular and Thoracic Institute, Cleveland, Ohio
  • 25Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
  • 26Department of Medicine, Tufts Medical Center, Boston, Massachusetts
  • 27Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
  • 28Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
  • 29Faculty of Medicine and Health, Royal Prince Alfred Hospital/Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
  • 30Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
  • 31Department of Family Medicine, University of Washington, Seattle
  • 32Department of Pediatrics, University of Iowa, Iowa City
  • 33Department of Internal Medicine, University of Texas, Southwestern, Dallas
  • 34Institute of Cardiovascular Medicine, University College London, London, United Kingdom
  • 35Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston
  • 36Department of Internal Medicine, University of Iowa, Iowa City
  • 37Department of Pediatric Cardiology, St Luke’s Health System, Boise, Idaho
  • 38Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
  • 39National Heart and Lung Institute & MRC London Institute of Medical Sciences, Imperial College London/ Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust
  • 40Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
JAMA Cardiol. 2023;8(6):595-605. doi:10.1001/jamacardio.2023.1042
Key Points

Question  Is vigorous exercise associated with an increased risk of mortality or ventricular arrhythmia in individuals with hypertrophic cardiomyopathy (HCM)?

Findings  In this cohort study including 1660 participants, individuals exercising vigorously did not have an associated higher mortality or a higher incidence of ventricular arrhythmias.

Meaning  In this study, these data do not support universal restriction of vigorous exercise for individuals with HCM.


Importance  Whether vigorous intensity exercise is associated with an increase in risk of ventricular arrhythmias in individuals with hypertrophic cardiomyopathy (HCM) is unknown.

Objective  To determine whether engagement in vigorous exercise is associated with increased risk for ventricular arrhythmias and/or mortality in individuals with HCM. The a priori hypothesis was that participants engaging in vigorous activity were not more likely to have an arrhythmic event or die than those who reported nonvigorous activity.

Design, Setting, and Participants  This was an investigator-initiated, prospective cohort study. Participants were enrolled from May 18, 2015, to April 25, 2019, with completion in February 28, 2022. Participants were categorized according to self-reported levels of physical activity: sedentary, moderate, or vigorous-intensity exercise. This was a multicenter, observational registry with recruitment at 42 high-volume HCM centers in the US and internationally; patients could also self-enroll through the central site. Individuals aged 8 to 60 years diagnosed with HCM or genotype positive without left ventricular hypertrophy (phenotype negative) without conditions precluding exercise were enrolled.

Exposures  Amount and intensity of physical activity.

Main Outcomes and Measures  The primary prespecified composite end point included death, resuscitated sudden cardiac arrest, arrhythmic syncope, and appropriate shock from an implantable cardioverter defibrillator. All outcome events were adjudicated by an events committee blinded to the patient’s exercise category.

Results  Among the 1660 total participants (mean [SD] age, 39 [15] years; 996 male [60%]), 252 (15%) were classified as sedentary, and 709 (43%) participated in moderate exercise. Among the 699 individuals (42%) who participated in vigorous-intensity exercise, 259 (37%) participated competitively. A total of 77 individuals (4.6%) reached the composite end point. These individuals included 44 (4.6%) of those classified as nonvigorous and 33 (4.7%) of those classified as vigorous, with corresponding rates of 15.3 and 15.9 per 1000 person-years, respectively. In multivariate Cox regression analysis of the primary composite end point, individuals engaging in vigorous exercise did not experience a higher rate of events compared with the nonvigorous group with an adjusted hazard ratio of 1.01. The upper 95% 1-sided confidence level was 1.48, which was below the prespecified boundary of 1.5 for noninferiority.

Conclusions and Relevance  Results of this cohort study suggest that among individuals with HCM or those who are genotype positive/phenotype negative and are treated in experienced centers, those exercising vigorously did not experience a higher rate of death or life-threatening arrhythmias than those exercising moderately or those who were sedentary. These data may inform discussion between the patient and their expert clinician around exercise participation.

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