Recommendations for participation in competitive sport in athletes with hypertrophic cardiomyopathy: opening the sacks of Aeolus

This commentary refers to ‘Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC)’, by A. Pelliccia et al., 2019;40:19–33. In a recent article in EHJ by Peliccia et al.,1 authors provide updated recommendations concerning eligibility of athletes with hypertrophic cardiomyopathy (HCM) for competitive sport (CS), suggesting that for HCM athletes without sudden cardiac death (SCD) risk factors, ‘systematic restriction from CS is probably unjustified’. It is evident that, SCD risk factors for HCM bear overall a very low positive predictive value.2 The HCM risk score, introduced by 2014 European Society of Cardiology (ESC) guidelines, has a better SCD predictability. However, it has never been validated in competitive athletes and its application in them is officially discouraged from ESC.2 Even from a post hoc analysis of a previous study by Peliccia et al.,3 proposed SCD criteria have a sensitivity of 0%, a specificity of 88%, and an informedness of −0.12, representing their perverse use in athletes. Another argument used, is the low SCD prevalence among HCM athletes continuing CS. Authors support, based on previous studies, that SCD prevalence may be as low as 1 out of 15 HCM athletes continuing sports (annual rate 0.3%).1 , 3 Even though SCD incidence rate is low and non-significantly different compared to HCM athletes not continuing CS, it is at least 15 times higher compared to a 19-year-old, male, black, basketball player who has the worst SCD risk profile according to the literature (1/5200 events per year).4 Nonetheless, allowing high risk athletes to participate in CS puts into doubt the importance of pre-participation screening policy. In conclusion, even though we favour a personalized approach and a shared decision-making process in the assessment of our HCM athletes, current recommendations lack solid evidence. Guiding HCM athletes towards participation in CS needs far more sufficient criteria. Conflict of interest: none declared. The authors of ehz475 were invited to submit a response to Discussion Forum contribution (ehy730), but opted not to.