Getting ahead of sudden cardiac arrest in pediatric hypertrophic cardiomyopathy patients

INTRODUCTION: Sudden cardiac arrest (SCA) remains one of the most devastating complications of pediatric hypertrophic cardiomyopathy (HCM). Despite major advances in genetic diagnostics, cardiac imaging, and risk stratification strategies, the prevention of sudden cardiac death (SCD) in children and adolescents with HCM remains an unresolved clinical challenge. Contemporary guideline-based approaches and pediatric-specific risk models have improved decision-making regarding implantable cardioverter-defibrillator (ICD) implantation in diagnosed patients; however, these strategies are inherently limited by their reliance on an established HCM phenotype. A substantial proportion of pediatric patients experience SCA as the initial clinical manifestation of disease, without any warning symptoms. AREAS COVERED: In this expert review, we conducted a MEDLINE-based literature search using the keywords HCM, SCA, and pediatric to synthesize current evidence on the epidemiology, age-specific characteristics, and arrhythmogenic mechanisms of pediatric HCM, and also highlight the limitations of existing risk stratification models and prevention strategies. We discuss emerging insights into electrical vulnerability that may precede overt structural disease, as well as the evolving role of electrocardiography-based screening strategies. EXPERT OPINION: By integrating clinical experience with recent advances - including artificial intelligence - enhanced electrocardiography - we propose a shift from post-diagnosis risk prediction toward upstream detection of vulnerable individuals.