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Updated: May 5, 2026
Evaluation of Left Ventricular Structure and Function using 3D Echocardiography
Published on: October 28, 2020
Exercise echocardiography in asymptomatic HCM: exercise capacity, and not LV outflow tract gradient predicts
Milind Y Desai1, Aditya Bhonsale1, Parag Patel1
1Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Exercise stress testing effectively risk-stratifies asymptomatic hypertrophic cardiomyopathy (HCM) patients. Achieving over 100% of predicted metabolic equivalents (METs) indicates a low event rate, highlighting its prognostic value.
Area of Science:
- Cardiology
- Cardiovascular Imaging
- Exercise Physiology
Background:
- Hypertrophic cardiomyopathy (HCM) often involves left ventricular outflow tract (LVOT) obstruction, mitral regurgitation (MR), and diastolic dysfunction.
- While many HCM patients require intervention, a subset of asymptomatic individuals can be monitored non-invasively.
- Exercise echocardiography is a valuable tool for assessing functional capacity and risk in HCM patients.
Purpose of the Study:
- To evaluate long-term outcomes in asymptomatic or minimally symptomatic HCM patients using exercise echocardiography.
- To determine the prognostic significance of exercise variables in predicting adverse events without invasive therapy.
Main Methods:
- 426 HCM patients underwent exercise echocardiography, excluding those with specific comorbidities or prior invasive treatment.
- Collected data included LV thickness, LVOT gradient, MR, percent predicted METs, and heart rate recovery (HRR).
- A composite endpoint of death, defibrillator discharge, or heart failure admission was tracked over a mean follow-up of 8.7 years.
Main Results:
- 82% of patients achieved less than 100% of predicted METs; 43% had significant post-stress MR.
- Higher predicted METs (>100%) correlated with a 1% event rate, compared to 12% for <85%.
- Independently significant predictors of outcome included percent predicted METs, abnormal HRR, and atrial fibrillation.
Conclusions:
- Exercise stress testing offers robust risk stratification for asymptomatic/minimally symptomatic HCM patients.
- Patients achieving >100% predicted METs demonstrate a favorable prognosis with a low risk of adverse events.
Objectives:
This study sought to assess long-term outcomes in asymptomatic or minimally symptomatic patients with hypertrophic cardiomyopathy (HCM) who underwent exercise echocardiography, without invasive therapies for relief of left ventricular outflow tract (LVOT) obstruction.
Background:
Many HCM patients present with LVOT obstruction, mitral regurgitation (MR), and diastolic dysfunction, often requiring invasive therapies for symptomatic relief. However, a significant proportion of truly asymptomatic patients can be closely monitored. In HCM patients, exercise echocardiography has been shown to be a useful assessment of functional capacity and risk stratification.
Methods:
We included 426 HCM patients (44 ± 14 years; 78% men) undergoing exercise echocardiography, excluding hypertensive heart disease of elderly, ejection fraction <50% and invasive therapy (myectomy or alcohol ablation) during follow-up. Clinical, echocardiographic (LV thickness, LVOT gradient, and MR) and exercise variables (percent of age-sex predicted metabolic equivalents [METs] and heart rate recovery [HRR] at 1 min post-exercise) were recorded. A composite endpoint of death, appropriate internal defibrillator discharge, and admission for congestive heart failure was recorded.
Results:
Patients were asymptomatic or minimally symptomatic on history, but 82% of patients achieved <100% of age-sex predicted METs, and 43% had ≥II+ post-stress MR. The mean LV septal thickness, post-exercise LVOT gradient, and HRR were 2.0 ± 0.5 cm, 62 ± 47 mm Hg, and 31 ± 14 beats/min, respectively. During a mean follow-up of 8.7 ± 3 years, there were 52 events (12%). Patients achieving >100% of age-sex predicted METs had 1% event rate versus 12% in those achieving <85%. On stepwise multivariate survival analysis, percent of age-sex predicted METs (hazard ratio [HR]: 0.76; 95% confidence interval [CI]: 0.64 to 0.90), abnormal HRR (HR: 0.89; 95% CI: 0.82 to 0.97), and atrial fibrillation (HR: 2.73; 95% CI: 1.30 to 5.74) (overall, p < 0.001) independently predicted outcomes.
Conclusions:
In asymptomatic or minimally symptomatic HCM patients, exercise stress testing provides excellent risk stratification, with a low event rate in patients achieving >100% of predicted METs.
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