In asymptomatic HCM patients, a VO₂ max <18 ml/kg/min predicted a nearly five-fold increased risk of major adverse cardiovascular events over 12 years.
Does cardiopulmonary exercise testing predict major adverse cardiovascular events in patients with hypertrophic cardiomyopathy?
Cardiopulmonary exercise testing, specifically VO2 max <18 ml/kg/min, is a strong independent predictor of long-term adverse cardiovascular outcomes in patients with hypertrophic cardiomyopathy, including those who are asymptomatic.
Abstract Background Hypertrophic cardiomyopathy (HCM) is a complex cardiac disorder characterized by left ventricular (LV) hypertrophy. Accurate risk stratification is essential for guiding clinical management and determining the need for advanced therapies. While cardiopulmonary exercise testing (CPET) is recognized by the American Heart Association (AHA) as a tool to identify risk factors for adverse outcomes, its prognostic value in asymptomatic adults with HCM remains uncertain, receiving a Class IIb recommendation. Objective To evaluate the prognostic role of CPET in predicting major adverse cardiovascular events (MACE) in a cohort of HCM patients, regardless of symptomatic status. Methods We prospectively enrolled 155 HCM patients (mean age 43±16 years; 28% women) in sinus rhythm with preserved LV ejection fraction (EF) (50%). The cohort included 93 asymptomatic patients, 52 with New York Heart Association (NYHA) Class II symptoms, and 9 with NYHA Class III symptoms. All participants underwent symptom-limited CPET following echocardiographic assessment. The composite MACE endpoint included sudden death (SD), heart transplantation and/or heart failure death (HF), progression to end-stage HCM (LVEF 50%) (ES-HCM), or the need for septal reduction therapies (SRT). Results Over a mean follow-up of 12±9 years (IQR 4–18 years), 38 patients experienced MACE (SD = 9; HF = 8; ES-HCM = 11; SRT = 10). Table reports differences between patients with and without MACE. Multivariable Cox regression using variables significantly different at univariate analysis, identified a VO₂ max 18 ml/kg/min and NYHA Class I as independent predictors of MACE (Figure, left upper and bottom panels, respectively). In asymptomatic patients, abnormal VO₂ max was the only predictor of outcome with an almost five-fold increased risk of MACE, with risk divergence becoming more apparent after 10 years of follow-up (Figure, right panel). Conclusions CPET provides valuable prognostic information in HCM patients, including those who are asymptomatic. VO₂ max serves as a robust, independent predictor of long-term adverse cardiovascular outcomes, supporting its role in comprehensive risk stratification for this population.Table 1 Figure 1
Ordine et al. (2025) studied this question. In asymptomatic HCM patients, a VO₂ max <18 ml/kg/min predicted a nearly five-fold increased risk of major adverse cardiovascular events over 12 years.