Are patients with hypertrophic cardiomyopathy given appropriate advice on exercise at a central London inherited cardiac conditions outpatient service?
Authors: Jayaratne N , Sonthikaew K , Halliday B , Abdi A , Pantazis A , Baksi J , Prasad S , Gati S 
Published: June 2024

ESC 2005 and AHA guidelines 2015 in sports cardiology restricted individuals with hypertrophic cardiomyopathy (HCM) from moderate and high intensity exercise and limited them to low intensity sport.1,2 Perceived increased risk of sudden cardiac death (SCD) with vigorous exercise in individuals with HCM was based on early registry data from the United States.3 This enforced sedentary lifestyle has led to an increasing trend towards obesity, atrial fibrillation and atherosclerotic coronary artery disease in patients with HCM.4 Recent ESC 2020 guidelines on exercise5 has enabled clinicians to recommend safe levels of exercise for these patients.

We audited how well our outpatient practice reflected the guidance set out in 2020 ESC guidelines on exercise for patients with cardiovascular disease.

Electronic records of 731 patients with a clinical diagnosis of HCM seen in our outpatient service between 2008-2023 were audited to determine whether written advice on exercise was given and if this was in line with current ESC guidelines at any encounter.

731 patients with a mean age of 62±14.5 (range 17-91 years) were seen in our specialist outpatient service. 68% were male. 51% of patients received exercise advice either at their initial visit ± a follow-up visit. A significant proportional increase (16%,P&lt;0.001) was seen in the number of patients receiving exercise advice at their initial visit after publication of the ESC 2020 guidelines (Table 1). 43% (270/634) of those who had their initial visit pre-guidelines received updated exercise advice as per 2020 ESC guidelines during follow-up. There was an increase in the proportion of patients receiving exercise advice each year after publication of ESC guidelines (Graph 1). Immediately following the publication, a high proportion received specific advice pertaining to intensity and duration of exercise (68% in 2020) with a slight decline subsequently (43%, 36% and 47% in 2021, 2022 and 2023 respectively). 27 patients had an implantable cardioverter defibrillator (ICD) in situ at the time of initial review with a further 127 undergoing ICD insertion under our care. SCD risk was documented for 66% (468/704) of patients according to the 2014 ESC Risk-SCD Model. 63% (214/338) of low risk patients received exercise advice, whilst 77% (40/52) and 54% (42/78) of intermediate and high risk patients received exercise advice respectively. 22 deaths (3%) were recorded during the follow-up period with none occurring during exercise. All cases except 2 were non-cardiac related.

An overall improvement was seen in our practice with a significant increase in the number of patients receiving exercise advice after publication of the new guidelines. Despite this, only 51% of our patients received any written guidance on exercise demonstrating a need for further improvement in our outpatient practice to reflect the paradigm shift in the approach to exercise in individuals with HCM as set out by ESC 2020 guidance.