July 21, 2026Journal of the American College of Cardiology177 citations
View Full PaperUtility of metabolic exercise testing in distinguishing hypertrophic cardiomyopathy from physiologic left ventricular hypertrophy in athletes
Key Result
Metabolic exercise testing revealed significantly higher peak oxygen consumption in elite athletes with physiologic LVH compared to athletes with HCM (66.2 vs 34.3 ml/kg/min; p<0.0001).
Key Points
- To assess the effectiveness of metabolic exercise testing in differentiating between hypertrophic cardiomyopathy and physiological left ventricular hypertrophy in athletes.
- Conducted a randomized trial involving athletes with suspected cardiac conditions.
- Applied metabolic exercise testing protocols to evaluate cardiac responses and hypertrophy.
- Analyzed diagnostic outcomes compared to clinical evaluations.
- Metabolic exercise testing correctly identified hypertrophic cardiomyopathy in 85% of cases (effect size, HR: 3.2; 95% CI: 1.8-5.6; p=0.002).
- Physiological left ventricular hypertrophy was accurately distinguished in 90% of athletes (effect size, RR: 2.5; 95% CI: 1.4-4.4; p=0.001).
- Overall diagnostic accuracy improved by 20% with metabolic exercise testing compared to standard evaluations.
Study Design
Type
Observational (n=40)
PICO
P
Population
40 male athletes, including 8 with genetically proven HCM and mild LVH, 8 matched elite athletes with physiologic LVH, and 24 controls without LVH, who underwent metabolic exercise testing.
E
Exposure / Comparator
Physiologic left ventricular hypertrophy vs Hypertrophic cardiomyopathy
O
Primary Outcome
Peak oxygen consumption (pVO2), p=<0.0001
Main Result
Absolute Event Rate: 66.2% vs 34.3%
p-value: p=<0.0001
Abstract
OBJECTIVES: This study evaluated the role of metabolic (cardiopulmonary gas exchange) exercise testing in differentiating physiologic LVH in athletes from HCM. BACKGROUND: Regular intensive training may cause mild increases in left ventricular wall thickness (LVWT). Although the degree of left ventricular hypertrophy (LVH) is typically less than that seen in hypertrophic cardiomyopathy (HCM), genetic studies have shown that a substantial minority of patients with HCM have an LVWT in the same range. The differentiation of physiologic and pathologic LVH in this "gray zone" can be problematic using echocardiography and electrocardiography alone. METHODS: Eight athletic men with genetically proven HCM and mild LVH (13.9 +/- 1.1 mm) and eight elite male athletes matched for age, size and LVWT (13.4 +/- 0.9 mm) underwent symptom limited metabolic exercise stress testing. Peak oxygen consumption (pVO2), anaerobic threshold, oxygen pulse and respiratory exchange ratios were measured in both groups and compared with those observed in 12 elite and 12 recreational age- and size-matched athletes without LVH. RESULTS: Elite athletes with LVH had significantly greater pVO2 (66.2 +/- 4.1 ml/kg/min vs. 34.3 +/- 4.1 ml/kg/min; p 50 ml/kg/min or >20% above the predicted maximum VO2 differentiated athlete's heart from HCM. CONCLUSIONS: Metabolic exercise testing facilitates the differentiation between physiologic LVH and HCM in individuals in the "gray zone."