Cumulative exercise-induced left ventricular systolic and diastolic dysfunction in hypertrophic cardiomyopathy

doi:10.1016/j.ijcard.2006.11.030

International Journal of Cardiology

Volume 122, Issue 1, 31 October 2007, Pages 76-78

https://doi.org/10.1016/j.ijcard.2006.11.030 Get rights and content

Abstract

The phenomenon of cumulative exercise-induced left ventricular function impairment was studied in 40 patients with non-obstructive hypertrophic cardiomyopathy with resting normal left ventricular function and no increase in ejection fraction on exercise. All patients underwent two symptom-limited exercise tests one-hour apart. Cumulative myocardial dysfunction was seen in 13 patients (group I) but not in the remaining 27 patients (group II). During follow-up, group I showed more commonly than group II a deterioration in symptoms (67% vs 22%, P = 0.025) and left ventricular function (50% vs 9%, P = 0.019). In conclusion, cumulative exercise-induced myocardial dysfunction can occur in hypertrophic cardiomyopathy and may be associated with clinical deterioration and worse outcome.

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In this study, the primary determinant of poor cardiac reserve was failure of stroke volume augmentation. In an earlier study, exercise-induced myocardial dysfunction was associated with clinical deterioration and worse outcomes.74 Although these studies show that poor exercise capacity is a predictor of adverse outcomes in HCM patients, whether exercise could accelerate or, on the other hand, attenuate the progression of disease, is unknown.
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Similar observations of cardiac fibrosis were reproduced in a rat model of long term intensive exercise training.37 In patients with HCM, intensive and rigorous exercise has been hypothesized to result in disease progression through promotion of LVH and myocardial ischemia leading to myocardial fibrosis as well as development of LV systolic and diastolic dysfunction.38 Interestingly, however, the results of a study using a mouse model of HCM contradict this belief.39
Hypertrophic cardiomyopathy is a common genetic disorder with a prevalence of 1:500 in the general population. Amongst a varied spectrum of clinical presentations, the most feared complication of this cardiac disorder is sudden cardiac death. Although only a minority of patients with hypertrophic cardiomyopathy who suffer sudden cardiac death or resuscitated cardiac arrest do so during exercise, strenuous physical activity is regarded as an important trigger for these tragic outcomes. Furthermore, during exercise, patients with hypertrophic cardiomyopathy may develop augmentation of left ventricular outflow tract obstruction, myocardial ischemia, diastolic dysfunction and/or inappropriate vasodilation in non-exercising vascular beds. This in turn may lead to exertional dyspnea, chest pain or syncope. Accordingly, patients with hypertrophic cardiomyopathy are disqualified from competitive sports and in many cases are recommended to avoid strenuous physical activity of any kind. Nevertheless, avoidance of physical activity comes with a price. The positive effects of regular exercise have been extensively reported to convey a wide range of benefits including reduced cardiovascular events, weight reduction and improved wellbeing. Therefore, finding the right exercise level that will offer some of the benefits of physical activity without increasing the risk of sudden cardiac death is of utmost importance. In this review, we discuss the current evidence for and against exercise in this patient population and review national guideline recommendations. We also propose alternative fitness strategies including a novel fitness program implemented by our hypertrophic cardiomyopathy center which may be of particular usefulness for hypertrophic cardiomyopathy patients.
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These studies suggest that the risk of SCD associated with exercise is grossly overestimated in practice. There is also a hypothetical consideration that vigorous exercise could promote the progression of the underlying HCM disease process through myocardial ischemia or the development of LV systolic or diastolic dysfunction.40–42 High-intensity exercise training has also been shown to promote the development of AF, and athletes with HCM may be more predisposed than athletes with a structurally normal heart.43,44
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^☆: This paper was presented in part at the Annual Scientific Session of the American College of Cardiology, 6–9 March, 2004, New Orleans, Louisiana.

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Letter to the EditorCumulative exercise-induced left ventricular systolic and diastolic dysfunction in hypertrophic cardiomyopathy☆

Abstract

Int J Cardiol

Hypertrophic cardiomyopathy: a systematic review

JAMA

Eur Heart J

Letter to the Editor
Cumulative exercise-induced left ventricular systolic and diastolic dysfunction in hypertrophic cardiomyopathy☆