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Table of Contents
Year : 2023  |  Volume : 12  |  Issue : 1  |  Page : 27-30

Hypertrophic cardiomyopathy in a healthy footballer undergoing knee surgery

1 Sports Medicine Unit, Faculty of Medicine, University of Malaya; Department of Sports Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
2 Department of Orthopedic, Sports Medicine Unit, Hospital Tengku Ampuan Rahimah Klang, Klang, Selangor, Malaysia

Date of Submission29-Dec-2022
Date of Decision21-Mar-2023
Date of Acceptance31-Mar-2023
Date of Web Publication27-Jun-2023

Correspondence Address:
Mohamad Shariff A Hamid
Sports Medicine Unit, Faculty of Medicine, University of Malaya; Department of Sports Medicine, University Malaya Medical Centre, Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mohe.mohe_38_22

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We described a 23-year-old male with no known medical illness, diagnosed with non-obstructive hypertrophic cardiomyopathy (HCM). The patient was scheduled for arthroscopic anterior cruciate ligament reconstruction surgery following an injury he sustained during football game few years ago, which he played leisurely. Prior to induction of general anaesthesia, the cardiac monitor showed abnormal deep T-wave inversion in leads II, III, aVF and V1–V6. The surgery was cancelled, and he was referred for further cardiac evaluation. Clinically, he was asymptomatic of heart condition with New York Heart Association Class 1. A further investigation revealed that he had non-obstructive HCM. A further investigation revealed that he had non-obstructive HCM with Modified Lee's cardiac risk assessment before non-cardiac surgery was 6.6% (moderate risk). We treated his left knee injury conservatively and advised him on being physically active based on the European Society of Cardiology Guidelines 2020.

Keywords: Cardiomyopathy, exerciser, knee cruciate ligament, sports participation, sudden cardiac death

How to cite this article:
Lai LC, Karim SA, Chiu JY, Hamid MS. Hypertrophic cardiomyopathy in a healthy footballer undergoing knee surgery. Malays J Mov Health Exerc 2023;12:27-30

How to cite this URL:
Lai LC, Karim SA, Chiu JY, Hamid MS. Hypertrophic cardiomyopathy in a healthy footballer undergoing knee surgery. Malays J Mov Health Exerc [serial online] 2023 [cited 2023 Sep 25];12:27-30. Available from: http://www.mohejournal.org/text.asp?2023/12/1/27/379849

  Introduction Top

Hypertrophic cardiomyopathy (HCM) is an autosomal-dominant cardiac disease, with underlying pathology of left ventricular hypertrophy (LVH), myofibre disarray, small vessel disease and fibrosis (Lu et al., 2018). Globally, the prevalence of HCM is one in every 500 people (He et al., 2021). A higher prevalence of one in every 200 people was reported amongst individuals with a family history of HCM (He et al., 2021). HCM is the leading cause of sudden cardiac death (SCD) in young adults (Maron et al., 2016; Pelliccia et al., 2021).

The European Society of Cardiology (ESC) Guidelines 2021 (Pelliccia et al., 2021) recommended a diagnosis of HCM based on the presence of unexplained LVH, with the maximum end-diastolic wall thickness of ≥15 mm in any myocardial segment, detected by (i) echocardiography (ECHO), (ii) cardiac magnetic resonance or (iii) computed tomography imaging. Individuals with lesser degrees of LVH (wall thickness ≥13 mm) who have a family history of definite HCM or a positive genetic test may also be considered for HCM. HCM is further classified into obstructive HCM with resting left ventricular outflow tract (LVOT) gradient ≥30 mmHg and non-obstructive HCM with rest/stress LVOT gradient <30 mmHg (Pelliccia et al., 2021). Labile obstruction is a type of obstructive HCM when there is obstruction with provocation. In labile obstruction, the LVOT gradient at rest is normal (<30 mmHg) but increased to ≥30 mmHg upon physiologic provocation (Pelliccia et al., 2021).

An exerciser is an individual who participates in physical activity (PA) with the intent of improving fitness, promoting health, betterment of one's physique and skills (Campa and Coratella, 2021), usually exercise for 2½ h/week. The ESC Guidelines 2020 (Pelliccia et al., 2021) defines athlete as an individual of young or adult age who engages in regular exercise training and participates in sports competition. Systematic training or exercise results in physiological adaptation of the cardiovascular system including benign hypertrophy of cardiac mass in addition to adaptation of vascular system (He et al., 2021). The resulting cardiac remodelling resembles certain structural or conductive abnormalities associated with SCD during strenuous activities (Maron et al., 2016). A competitive athlete invests more than 10 h/week of exercise versus a recreational athlete, spending at least 4 h/week (Pelliccia et al., 2021; Ariffin et al., 2020).

Anterior cruciate ligament (ACL) injuries are amongst the most common type of football injuries at all levels of competition, and they are associated with significant mid- and long-term consequences. The injury occurs following sudden pivoting or cutting manoeuvre during sports activities or due to motor vehicle accidents, which results in anterior and lateral rotatory instability of the knee. ACL injuries are managed both with physiotherapy and operatively through ACL reconstruction. The main aim of the treatment is to restore functional stability to the knee (Saueressig et al., 2022).

There is a report on HCM in athlete population in Malaysia (Ariffin et al., 2020), but this is the first case of incidental finding of an asymptomatic exerciser with non-obstructive HCM and concomitant ACL injury reported.

This case shed the light of management for young individuals with non-obstructive HCM with holistic approach involving different medical professionals. We counselled the patient regarding his PA with non-obstructive HCM and treated his underlying ACL injury accordingly with currently available knowledge.

  Case Report Top

A 23-year-old, Malay male, factory worker complained of left knee pain and instability for the past 1 year. He was kicked by an opponent over the left knee during a football game. He heard a 'pop' sound and noticed immediate swelling over the left knee. Since injury, he has been complaining of dull aching pain and instability when going down stairs. This affected his activity of daily living which he is unable to return to leisure activities such as light jogging.

A physical examination revealed a full active range of motion with no joint line tenderness. However, he was found to have positive anterior drawer test and Lachman test. Subsequently, a left knee magnetic resonance imaging (MRI) was done and confirmed the diagnosis of left knee ACL complete tear with lateral meniscus injury. He was then referred to an orthopaedic surgeon and arranged for left ACL reconstruction with meniscus repair. However, prior to induction of general anaesthesia, the anaesthetist noted that the patient had deep T-wave inversion in leads II, III, avF and V1–V6 on the cardiac monitor. The surgery was cancelled and he was referred to a cardiology team for further evaluation.

The patient denies experiencing chest pain, breathlessness, palpitations, orthopnoea or dyspnoea when his medical history was further probed. He has no medical illness and denied a family history of SCD, ischaemic heart disease or cardiomyopathy. He previously played football leisurely with friends, on average 2–3 h/month. His work scope requires him to walk at least 8000 steps/day. He is a non-smoker.

His Holter 24-h monitoring was normal. ECHO and cardiac MRI consistently showed apical HCM with interstitial fibrosis. His left ventricular ejection fraction was normal (69%), with no evidence of LVOT obstruction or pericardial effusion. The left ventricle mass, wall motion and left atrium size were within the normal range. Based on the ESC HCM Guidelines, his SCD in 5 years is estimated as 3% (low risk). Therefore, an implantable cardiac defibrillator is not indicated as a treatment option. In addition, the patient does not require the use of any medication such as beta-blocker at this stage. He was given clearance to return to sports, with yearly follow-up with the cardiologist for surveillance assessment. According to the modified Lee's risk assessment, the estimated probability of adverse outcome with non-cardiac surgery was 6.6%, implying a moderate chance of developing myocardial infarction, pulmonary oedema, ventricular fibrillation, cardiac arrest or complete heart block, if surgery was done.

After discussion with the orthopaedic surgeon, he opted for conservative treatment for his left knee injury. He is currently under the Sports Medicine Unit for continuation of individualised, structured and rehabilitative programmes with the aim to reduce his instability. He was advised to remain physically active and allowed low-to-moderate intensity level activity of exercise based on the ESC Guidelines 2020. He was taught on methods to monitor his heart rate intensity and to maintain exercise at the recommended intensity. In addition, awareness of automated defibrillator and importance of cardiopulmonary resuscitation were emphasised to his family and friends. He was made aware that he will require a long-term follow-up with the cardiologist.

During his latest follow-up (1 year treated for ACL and 7 months since diagnosed with HCM), he has no knee pain and instability symptoms at work, during his daily activities and during sports. He is able to play football and futsal leisurely at least 2–3 times/month, each session lasting 30–45 min. He also adheres closely to the prescribed ACL rehabilitative programme. Improvement in ACL laxity was noted in the objective KT-1000 knee stability test. The left knee KT-1000 readings improved from 10 mm (before ACL rehabilitation) to 6 mm during the latest clinical assessment.

  Discussion Top

There are evidence that PA provides a wide range of physical, psychological, social and emotional benefits for individuals of all ages (Pelliccia et al., 2021). Moreover, PA is also a basis of both primary prevention and clinical management of many chronic diseases. It has been known that higher PA level and fitness are inversely related to all-cause mortality, cardiovascular diseases and malignancies. There is a role to differentiate between athlete and exerciser because, in athlete group, vigorous intensity training leads to morphological and physiological cardiovascular changes ('Athlete's Heart') secondary to increase in the haemodynamic workload (Pelliccia et al., 2021). The cardiac remodelling, especially in highly trained athletes, has similar characteristics with HCM. The clinical implication is essential as athlete's heart is a physiological change, but HCM is a pathological condition with risk of SCD amongst young individuals.

In general, obstructive HCM is associated with worse cardiac symptoms, diastolic function and largest left atrium size than non-obstructive HCM. Understandingly, more emphasis was given to this pool of patients with obstructive HCM. In 2016, Maron et al. reported 0.5% per year of HCM-related mortality amongst patients with non-obstructive HCM, with a 5-year and 10-year survival rate of 99% and 97%, respectively. Although non-obstructive HCM patients have lower mortality rates than obstructive HCM, they have higher rates of adverse clinical events. Myocardial fibrosis, microvascular ischaemia and varied unidentified factors can lead to the generation of malignant ventricular arrhythmias in non-obstructive HCM (Lu et al., 2018). Sustained ventricular fibrillation and ventricular tachycardia were commonly reported, followed by heart failure and death. Exercise is listed as a potential trigger for fatal arrhythmias amongst these individuals. The ESC Guidelines 2020 (Pelliccia et al., 2021) emphasise the need for equilibrium between protecting patients from potentially adverse effects of exercise and preventing morbidity burden on this cohort of patients through exercise. Based on Class IIB level evidence (Pelliccia et al., 2021), participation in high-intensity exercise or competitive sports is allowed for patients who do not have any markers of increased risk following expert assessment. The markers of increased risk include (a) cardiac symptoms or history of cardiac arrest or unexplained syncope, (b) moderate ESC risk score (>4%) at 5 years, (c) LVOT gradient at rest >30 mmHg, (d) abnormal blood pressure response to exercise and (e) exercise-induced arrhythmias. Patients with any markers of increased risks are recommended to participate in low- or moderate-intensity recreational exercise. Eventually, a shared decision-making is the key answer for individuals with HCM, who desires to participate in sports and exercise. Regular evaluation for the assessment of disease progression and risk re-stratification with objective assessment is recommended.

In Malaysia, there were studies on cardiovascular screening amongst athlete population. In a study conducted amongst 176 Malaysian university athletes, three cardiac abnormalities were detected; however, none were HCM (Lim et al., 2017). That said, cardiovascular screening as part of pre-participation evaluation was able to identify individuals with abnormal electrocardiograms (ECGs) for further investigations. Another study amongst Malaysian footballers reported 20% of abnormal ECGs during pre-participation evaluation of 85 footballers with two out of four ECHO-reported hypertrophic changes (Ariffin et al., 2020). Positive correlations between ECG and ECHO findings were useful in diagnosing pathological ECGs. Hence, cardiovascular screening aims to identify individuals with risk of SCD through personal history (including medical), physical examination and 12-lead ECGs. However, SCD events can occur in individuals with HCM who are otherwise unrecognised and not part of clinical cohorts or literature (Pelliccia et al., 2021). According to research conducted by Weissler-Snir et al. among Canadians (10-45 years old), SCD among patients with HCM occurs infrequently during exercise (Weissler-Snir et al., 2019). Moreover, majority of HCM-related SCDs were reported amongst individuals who are undiagnosed. Unfortunately, justifying a mandatory population-based national screening is an economically challenging and time-consuming task, although current research indicate the need for personal protective equipment for all competitive athletes (Ariffin et al., 2020; Lim et al., 2017).

In the case of ACL injury, a systematic review and meta-analysis by Saueressig et al. found no clinically relevant differences in most outcomes between early surgical reconstruction and primary rehabilitation with optional reconstruction (Saueressig et al., 2022). There is an emphasis on the importance of individualised and patient-centred forms of care, taking into account an individual's medical situation, anatomical differences, and functional demand. Furthermore, they also emphasised the role of functional instability, a determining factor for surgical intervention to minimise secondary joint damage. According to van der Graaff et al., predictors of unsatisfactory non-operative treatment include individuals with instability symptoms, pain during activity and reduced perception of knee function (van der Graaff et al., 2022). Individuals with higher pre-injury activity level and younger age group are those who would benefit from early reconstructive knee surgery.

  Conclusion Top

Being diagnosed with non-obstructive HCM with concomitant ACL injury should not deter an individual from being active. Individuals with non-obstructive HCM should be well informed about their existing heart conditions and necessitate the need to be compliant for annual cardiac surveillance to detect any markers of increased risk for cardiac events. Of note, these individuals should actively participate in sports and exercises, as it is the basic of primary prevention for all-cause mortality, cardiovascular diseases and malignancies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ariffin, F., Khir, R. N., Mohamed Yassin, M. S., Baharudin, N., Ismail, I. A., Abdul Hamid, H., & Abd Halim, H. (2020). Identifying electrocardiogram pattern changes and their association with echocardiography among Malaysian footballers attending pre-participation evaluation. Journal of Clinical and Health Sciences, 5(1), 49-59.  Back to cited text no. 1
Campa, F., & Coratella, G. (2021). Athlete or non-athlete? This is the question in body composition. Frontiers in Physiology, 12, 814572. doi: 10.3389/fphys.2021.814572.  Back to cited text no. 2
He, M., Qiu, J., Bai, Y., Wang, Y., Hu, M., & Chen, G. (2021). Non-pharmaceutical interventions for hypertrophic cardiomyopathy: A mini review. Frontiers in Cardiovascular Medicine, 8, 695247. doi: 10.3389/fcvm.2021.695247.  Back to cited text no. 3
Lim, Z. L., Mokhtar, A. H., & Jaffar, M. R. (2017). Pre-participation evaluation of Malaysian university athletes – The importance of cardiovascular screening. Movement, Health & Exercise, 6(2), 67-76.  Back to cited text no. 4
Lu, D. Y., Pozios, I., Haileselassie, B., Ventoulis, I., Liu, H., Sorensen, L. L., Canepa, M., Phillip, S., Abraham, M. R., & Abraham, T. P. (2018). Clinical outcomes in patients with nonobstructive, labile, and obstructive hypertrophic cardiomyopathy. Journal of the American Heart Association, 7(5), e006657. doi: 10.1161/JAHA.117.006657.  Back to cited text no. 5
Maron, M. S., Rowin, E. J., Olivotto, I., Casey, S. A., Arretini, A., Tomberli, B., Garberich, R. F., Link, M. S., Chan, R. H. M., Lesser, J. R., & Maron, B. J. (2016). Contemporary natural history and management of nonobstructive hypertrophic cardiomyopathy. Journal of the American College of Cardiology, 67(12), 1399-1409. doi: 10.1016/j.jacc.2016.01.023.  Back to cited text no. 6
Pelliccia, A., Sharma, S., Gati, S., Bäck, M., Börjesson, M., Caselli, S., Collet, J. P., Corrado, D., Drezner, J. A., Halle, M., Hansen, D., Heidbuchel, H., Myers, J., Niebauer, J., Papadakis, M., Piepoli, M. F., Prescott, E., Roos-Hesselink, J. W., Graham Stuart, A., Taylor, R. S., Thompson, P. D., Tiberi, M., Vanhees, L., Wilhelm, M., & ESC Scientific Document Group. (2021). 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. European Heart Journal, 42(1), 17-96. doi: 10.1093/eurheartj/ehaa605.  Back to cited text no. 7
Saueressig, T., Braun, T., Steglich, N., Diemer, F., Zebisch, J., Herbst, M., Zinser, W., Owen, P. J., & Belavy, D. L. (2022). Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: A living systematic review and meta-analysis. British Journal of Sports Medicine, 56(21), 1241-1251. doi: 10.1136/bjsports-2021-105359.  Back to cited text no. 8
van der Graaff, S. J. A., Meuffels, D. E., Bierma-Zeinstra, S. M. A., van Es, E. M., Verhaar, J. A. N., Eggerding, V., & Reijman, M. (2022). Why, when, and in which patients nonoperative treatment of anterior cruciate ligament injury fails: An exploratory analysis of the COMPARE trial. The American Journal of Sports Medicine, 50(3), 645-651. doi: 10.1177/03635465211068532.  Back to cited text no. 9
Weissler-Snir, A., Allan, K., Cunningham, K., Connelly, K. A., Lee, D. S., Spears, D. A., Rakowski, H., & Dorian, P. (2019). Hypertrophic cardiomyopathy-related sudden cardiac death in young people in Ontario. Circulation, 140(21), 1706-1716. doi: 10.1161/CIRCULATIONAHA.119.040271.  Back to cited text no. 10


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