Systematic Review on the Safety of Physical Exercise in Hypertrophic Cardiomyopathy: Recommendations from the Brazilian Society of Cardiology

Abstract

Background

Although historically discouraged due to the risk of arrhythmias and sudden cardiac death (SCD), physical exercise (PE) may be safe and beneficial for individuals with hypertrophic cardiomyopathy (HCM).

Objective

To evaluate the association between PE and the incidence of mortality and arrhythmic events in adults with HCM, stratifying the analysis according to different types and intensities of exercise.

Methods

Systematic review of randomized clinical trials (RCTs) and observational studies identified in PubMed, Embase, and the Cochrane Library through December 2024. Studies including individuals exposed to different intensities of PE were eligible. Risk of bias was assessed using the RoB 2 and ROBINS-I tools, and certainty of evidence using GRADE. Recommendations were developed by an expert panel of the Brazilian Society of Cardiology.

Results

Eight studies (four RCTs and four observational studies; 9,744 participants) were included. None reported an increased risk of mortality or severe arrhythmic events associated with PE, even at moderate or vigorous intensities. Syncope was rare. Additionally, a Korean observational study involving more than 7,000 participants (mean age: 59 years) demonstrated reduced all-cause mortality with higher physical activity intensity (dose–response curve). In low-risk athletes, competitive sports were not associated with severe adverse events. The quality of evidence ranged from moderate to very low.

Conclusion

PE in HCM should be encouraged based on individualized assessment. In patients without high-risk criteria for SCD, benefits appear to outweigh risks. For higher-risk subgroups, recommendations are more cautious and based on expert consensus.