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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic cardiomyopathy &#40;HCM&#41; remains a leading cause of sudden cardiac death &#40;SCD&#41; in young athletes and the classic decision regarding sports eligibility is the disqualification from competitive sport&#46; The 2020 European Society of Cardiology &#40;ESC&#41; guidelines on sports cardiology and exercise in patients with cardiovascular disease are more liberal&#44; emphasizing the multiple benefits of regular exercise and the shared decision making process&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent studies have shown a lower risk of SCD and exercise-induced implantable cardioverter defibrillator shocks in individuals with HCM than previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Pelliccia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> showed that over a nine-year follow-up in athletes with HCM who continued competitive sports&#44; there were no significant differences in the incidence of symptoms or major clinical events compared to athletes who ceased exercise&#46; Patients with HCM who engaged in exercise programs saw a significant improvement in functional capacity&#44; while other research has demonstrated that the majority of SCD cases occur at rest&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Although this evidence is promising&#44; due to the heterogenicity and broad spectrum of HCM risk&#44; the generalization of this message is simplistic and may lead to a wrong interpretation&#44; leading to potential prognostic implications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In fact&#44; several issues should be clarified in the relationship between HCM and exercise&#46; SCD can occur in the absence of major risk factors&#59; athletes participating in high endurance or extreme sports are exposed to conditions that cannot be reproduced in preparticipation evaluation and ESC-risk score have never been validated in athletes&#46; On the other hand&#44; a detailed analysis of ESC guidelines&#44; shows that recommendations for exercise in HCM have low class &#40;IIb&#41; and level of evidence &#40;C&#41; for high-intensity exercise&#47;competitive sports in the absence of any markers of increased risk&#59; low-moderate-intensity recreational exercise for individuals who have any marker and competitive sports for gene positiv&#47;phenotype negative cases&#46; In this context&#44; shared decision-making is broadly advocated&#44; combining the patients&#8217; principles&#44; preferences and autonomy&#44; but must not be oversimplified as a process in which only the athlete decides&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">After diagnosis&#44; risk stratification is essential to establish more accurate recommendations regarding sports eligibility and exercise prescription in HCM&#46; Major risk factors are common to all HCM patients&#58; prior cardiac arrest&#44; unexplained syncope&#44; family history of SCD&#44; high ESC-risk score&#44; left ventricular &#40;LV&#41; outflow tract obstruction&#44; massive ventricular wall thickness&#44; non-sustained ventricular tachycardia&#44; extensive myocardial fibrosis&#44; abnormal blood pressure response to exercise&#44; LV systolic disfunction or apical aneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The athlete&#39;s age and its impact on SCD risk &#40;mean age 18 years&#41; is very important&#44; while specific disciplines such as highly dynamic and start-stop sports are associated with increased risk&#46; Individuals with positive genotype and negative phenotype may engage in all sports&#44; but a regular follow-up is recommended&#44; mainly in adolescents&#47;young adults&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Individuals with HCM have different vulnerability to exercise-induced fatal arrhythmias and systematic restriction may be unjustified&#46; However&#44; the evidence is scarce to define the risk of SCD across all athletes and to investigate the safety of exercise in HCM&#44; making eligibility decisions challenging&#44; particularly in young competitive athletes&#46; In this setting&#44; a comprehensive approach is needed&#44; focusing on individualized risk stratification and exercise prescription &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The main issue is not whether exercise is possible in HCM&#44; but which athletes can exercise&#44; and which exercise is recommended&#46; The goal should not be to establish the same recommendation for all patients but choose the right recommendation for each individual patient&#46; Additional research is needed to determine the safety of sports in patients with HCM and develop evidence-based SCD risk stratification methods in this population&#46; Until then&#44; as in other areas of sports cardiology&#44; it is essential to balance the benefits and risks of exercise&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Research Letter
Exercise in hypertrophic cardiomyopathy: Yes or no?
Exercício na miocardiopatia hipertrófica: sim ou não?
Hélder Doresa,b
a Hospital da Luz Lisboa, Lisboa, Portugal
b NOVA Medical School, Lisboa, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertrophic cardiomyopathy &#40;HCM&#41; remains a leading cause of sudden cardiac death &#40;SCD&#41; in young athletes and the classic decision regarding sports eligibility is the disqualification from competitive sport&#46; The 2020 European Society of Cardiology &#40;ESC&#41; guidelines on sports cardiology and exercise in patients with cardiovascular disease are more liberal&#44; emphasizing the multiple benefits of regular exercise and the shared decision making process&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Recent studies have shown a lower risk of SCD and exercise-induced implantable cardioverter defibrillator shocks in individuals with HCM than previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Pelliccia et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> showed that over a nine-year follow-up in athletes with HCM who continued competitive sports&#44; there were no significant differences in the incidence of symptoms or major clinical events compared to athletes who ceased exercise&#46; Patients with HCM who engaged in exercise programs saw a significant improvement in functional capacity&#44; while other research has demonstrated that the majority of SCD cases occur at rest&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Although this evidence is promising&#44; due to the heterogenicity and broad spectrum of HCM risk&#44; the generalization of this message is simplistic and may lead to a wrong interpretation&#44; leading to potential prognostic implications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In fact&#44; several issues should be clarified in the relationship between HCM and exercise&#46; SCD can occur in the absence of major risk factors&#59; athletes participating in high endurance or extreme sports are exposed to conditions that cannot be reproduced in preparticipation evaluation and ESC-risk score have never been validated in athletes&#46; On the other hand&#44; a detailed analysis of ESC guidelines&#44; shows that recommendations for exercise in HCM have low class &#40;IIb&#41; and level of evidence &#40;C&#41; for high-intensity exercise&#47;competitive sports in the absence of any markers of increased risk&#59; low-moderate-intensity recreational exercise for individuals who have any marker and competitive sports for gene positiv&#47;phenotype negative cases&#46; In this context&#44; shared decision-making is broadly advocated&#44; combining the patients&#8217; principles&#44; preferences and autonomy&#44; but must not be oversimplified as a process in which only the athlete decides&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">After diagnosis&#44; risk stratification is essential to establish more accurate recommendations regarding sports eligibility and exercise prescription in HCM&#46; Major risk factors are common to all HCM patients&#58; prior cardiac arrest&#44; unexplained syncope&#44; family history of SCD&#44; high ESC-risk score&#44; left ventricular &#40;LV&#41; outflow tract obstruction&#44; massive ventricular wall thickness&#44; non-sustained ventricular tachycardia&#44; extensive myocardial fibrosis&#44; abnormal blood pressure response to exercise&#44; LV systolic disfunction or apical aneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The athlete&#39;s age and its impact on SCD risk &#40;mean age 18 years&#41; is very important&#44; while specific disciplines such as highly dynamic and start-stop sports are associated with increased risk&#46; Individuals with positive genotype and negative phenotype may engage in all sports&#44; but a regular follow-up is recommended&#44; mainly in adolescents&#47;young adults&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Individuals with HCM have different vulnerability to exercise-induced fatal arrhythmias and systematic restriction may be unjustified&#46; However&#44; the evidence is scarce to define the risk of SCD across all athletes and to investigate the safety of exercise in HCM&#44; making eligibility decisions challenging&#44; particularly in young competitive athletes&#46; In this setting&#44; a comprehensive approach is needed&#44; focusing on individualized risk stratification and exercise prescription &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The main issue is not whether exercise is possible in HCM&#44; but which athletes can exercise&#44; and which exercise is recommended&#46; The goal should not be to establish the same recommendation for all patients but choose the right recommendation for each individual patient&#46; Additional research is needed to determine the safety of sports in patients with HCM and develop evidence-based SCD risk stratification methods in this population&#46; Until then&#44; as in other areas of sports cardiology&#44; it is essential to balance the benefits and risks of exercise&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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ISSN: 08702551
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Revista Portuguesa de Cardiologia
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