Working Diagnosis:
Progressive Electrical Abnormalities Concerning For Early Hypertrophic Cardiomyopathy

Treatment:
No treatment

Outcome:
After research of existing guidelines and consultation of experts in the field of Sports Cardiology, our medical team met with the athlete and his family to discuss the possible risks of returning to participate in collegiate football. Following this discussion, the athlete ultimately decided to return to full participation in his collegiate sport.

The athlete is currently undergoing bi-annual electrocardiogram testing, annual echocardiograms, and serial follow ups to monitor clinical progression of any hypertrophic cardiomyopathy features. He has remained asymptomatic and was able to participate in the 2023-2024 football season without any limitations.

Author's Comments:
DISCUSSION:
With over 1,500 known genetic mutations, hypertrophic cardiomyopathy encompasses a large spectrum of molecular abnormalities that share a common phenotype of characteristic cardiac structural changes. A risk factor that influences the penetrance of hypertrophic cardiomyopathy gene mutations is participation in high-intensity sports. Hypertrophic cardiomyopathy may manifest itself with abnormal electrical patterns on electrocardiogram years before the development of clinical symptoms or hypertrophy on advanced imaging. Current guidelines for unequivocal hypertrophic cardiomyopathy, diagnosed with characteristic morphologic changes on imaging, are straightforward and advise against participation in any sport with increased dynamic and static cardiac loads. Conversely, for athletes with various clinical signs of hypertrophic cardiomyopathy, whether it be cardiac electrical signal changes or definitive cardiac structural findings, the discussion of returning to play is more nuanced and would require extensive counseling with ongoing follow up.

Editor's Comments:
As noted in this case, hypertrophic cardiomyopathy can have a multitude of manifestations. Oftentimes, there can be electrocardiogram findings that proceed any clinical symptoms, even in "high-intensity" sport athletes. Although avoiding higher cardiovascular strain athletics/activity is recommended for patients with hypertrophic cardiomyopathy, shared decision making, cardiologist evaluation, and routine follow up can also be indicated in athletes that have early electrocardiogram findings that are otherwise asymptomatic.

References:
Ommen, S. R., Mital, S., Burke, M. A., Day, S. M., Deswal, A., Elliott, P. M., Evanovich, L. L., Hung, J., Joglar, J. A., Kantor, P. F., Kimmelstiel, C., Kittleson, M., Link, M. S., Maron, M. S., Martinez, M. W., Miyake, C. Y., Schaff, H. V., Semsarian, C., & Sorajja, P. (2020). 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients with Hypertrophic Cardiomyopathy. Circulation (New York, N.Y.), 142(25).

Drezner, J. A., Malhotra, A., Prutkin, J. M., Papadakis, M., Harmon, K. G., Asif, I. M., Owens, D. S., Marek, J., &
Sharma, S. (2021). Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical
review. British Journal of Sports Medicine, 55(18), 1041–1048.

Maron, B. J., Udelson, J. E., Bonow, R. O., Nishimura, R. A., Ackerman, M. J., Estes, N. M., Cooper, L. T., Link, M. S., & Maron, M. S. (2015). Eligibility and disqualification recommendations for competitive athletes with
cardiovascular abnormalities: Task Force 3: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular
cardiomyopathy and other cardiomyopathies, and myocarditis. Circulation, 132(22).

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