25-Year Evolution of Apical Hypertrophic Cardiomyopathy in a Professional Athlete

Hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death in young athletes. Risk stratification and disease evolution in athletes who continue competitive sport, particularly in apical phenotypes, remain incompletely defined.

A 14-year-old academy football player was diagnosed with subclinical HCM during preparticipation screening and elected to continue competing despite contemporaneous guideline restrictions. Over 25 years of follow-up, he progressed to apical HCM with late gadolinium enhancement and mild ventricular ectopy but maintained excellent functional capacity and remained asymptomatic. After transferring to a lower-tier club, both palpitations and ventricular ectopy decreased. He completed a long professional career and developed an apical aneurysm shortly before retiring.

This case highlights the complexity of exercise counseling in HCM and is consistent with contemporary guideline-supported, individualized decision-making, as it illustrates that selected low-risk athletes may tolerate long-term competition. The extended follow-up highlights the long-term natural history of apical HCM in an athlete and underscores persistent uncertainties regarding phenotype-specific risk modifiers, including myocardial fibrosis and apical aneurysm formation.

Personalized, shared decision-making is essential in athletes with HCM, and refined risk-stratification models are urgently needed.