Safety and efficacy of physical activity in hypertrophic cardiomyopathy patients: a systematic review and metanalysis

Hypertrophic Cardiomyopathy (HCM) is a fairly common inherited cardiac disease, with a prevalence of about 1:200–1:500, characterized by left ventricular hypertrophy (LVH ≥15 mm) often associated with microvascular dysfunction, myocardial fibrosis and major ventricular arrhythmic events. Historically, HCM has been managed conservatively, with universal restrictions on vigorous physical activity due to concerns about ventricular arrhythmias and sudden cardiac death (SCD), particularly in the context of competitive sports. These recommendations, once codified in the 2020 AHA and ESC guidelines, led to significant secondary consequences including increased risk of obesity, metabolic syndrome, and psychological distress. The 2023 Italian Cardiology Protocols for Eligibility for Competitive Sport (COCIS), aligned with the European and American guidelines, provide a rigorous diagnostic framework for assessing risk in individuals with HCM. Although these protocols outline criteria for competitive sports eligibility, the evidence reviewed in this meta-analysis predominantly derives from studies investigating patients engaged in recreational or moderate-intensity exercise rather than competitive athletes. Therefore, the applicability of current findings to competitive sports participation remains limited and should be interpreted with caution. Recent evidence challenges the one-size-fits-all approach, emphasizing the therapeutic benefits and safety of regular moderate-intensity exercise in individuals with low-risk HCM. This paradigm shift is reflected in updated international guidelines, including the 2023 ESC and 2024 AHA/ACC recommendations, which now recognize that universal restriction from vigorous exercise is not warranted for most patients with HCM. These documents advocate for a more nuanced, individualized approach based on shared decision-making and comprehensive evaluation through cardiopulmonary exercise testing (CPET), exercise echocardiography, and longitudinal follow-up. The evolving role of exercise in HCM highlights the need for structured, personalized prescriptions that consider arrhythmic risk stratification and patient preferences and goals. The present work aims to critically synthesize contemporary evidence regarding HCM and physical activity, with particular focus on the incidence of major adverse cardiovascular events (MACE) in athletic populations, and the implications for future clinical management. The meta-analysis included 8 studies on 2217 patients with HCM, of whom 1204 were in the exercise group and 1013 in the control group. The results demonstrate that exercise is safe and does not increase the risk of MACE (RR 1.01, p = 0.97) and is effective in improving cardiorespiratory fitness (+1.76 ml/kg/min in VO2 peak, p < 0.0001). These results support the inclusion of structured and supervised exercise in the clinical management of patients with HCM.