Lifestyle Modification: Diet, Exercise, Sports, and Other Issues

  • David S. OwensEmail author


Patients with hypertrophic cardiomyopathy face a lifetime of living with a heart condition that is at once heterogeneous, often unpredictable, and incompletely understood. Lifestyle adjustments are essential to controlling symptoms, and factors such as diet, fluid intake, caffeine, alcohol, and exercise can all have profound effects on patient well-being. However, because HCM physiology can vary widely from patient to patient, physician recommendations must be personalized to each individual patient’s physiology, which also may change over the years. Hydration should be encouraged for patients with dynamic LVOT obstruction, but diuretics and strict regulation of fluid balance may be needed when congestion is present. Moreover, although exercise has myriad health benefits, it carries acute risks in HCM patients. Professional guidelines prohibit competitive sports and vigorous recreational activities, and this may have implications on patient employment. However, strict exercise proscriptions are not warranted, and in most cases moderate exercise should be encouraged as a component of a healthy lifestyle. As with nearly all aspects of HCM patient care, recommendations about lifestyle are not simple but require ongoing conversations tailored to individual patients. These conversations need to be placed in the context of each patient’s physiology and risks and informed by the patient’s overall life goals. Discussion with the patient and family, often repeated over multiple visits, will be necessary in order to develop the trust and partnership that leads to effective management.


Hypertrophic cardiomyopathy Diet Caffeine Alcohol Medications Supplements Sports Exercise Employment Insurance 


  1. 1.
    Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2011;124(24):e783–831.PubMedGoogle Scholar
  2. 2.
    Maron MS, Olivotto I, Zenovich AG, et al. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation. 2006;114(21):2232–9.CrossRefGoogle Scholar
  3. 3.
    Adams JC, Ommen SR, Klarich KW, Tajik AJ, Nishimura RA. Significance of postprandial symptom exacerbation in hypertrophic cardiomyopathy. Am J Cardiol. 2010;105(7):990–2.CrossRefGoogle Scholar
  4. 4.
    Kansal MM, Mookadam F, Tajik AJ. Drink more, and eat less: advice in obstructive hypertrophic cardiomyopathy. Am J Cardiol. 2010;106(9):1313–6.CrossRefGoogle Scholar
  5. 5.
    Feiner E, Arabadjian M, Winson G, Kim B, Chaudhry F, Sherrid MV. Post-prandial upright exercise echocardiography in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2013;61(24):2487–8.CrossRefGoogle Scholar
  6. 6.
    Harris KM, Spirito P, Maron MS, et al. Prevalence, clinical profile, and significance of left ventricular remodeling in the end-stage phase of hypertrophic cardiomyopathy. Circulation. 2006;114(3):216–25.CrossRefGoogle Scholar
  7. 7.
    Caldeira D, Martins C, Alves LB, Pereira H, Ferreira JJ, Costa J. Caffeine does not increase the risk of atrial fibrillation: a systematic review and meta-analysis of observational studies. Heart. 2013;99(19):1383–9.CrossRefGoogle Scholar
  8. 8.
    Chelsky LB, Cutler JE, Griffith K, Kron J, McClelland JH, McAnulty JH. Caffeine and ventricular arrhythmias. An electrophysiological approach. JAMA. 1990;264(17):2236–40.CrossRefGoogle Scholar
  9. 9.
    Newby DE, Neilson JM, Jarvie DR, Boon NA. Caffeine restriction has no role in the management of patients with symptomatic idiopathic ventricular premature beats. Heart. 1996;76(4):355–7.CrossRefGoogle Scholar
  10. 10.
    Zuchinali P, Souza GC, Pimentel M, et al. Short-term effects of high-dose caffeine on cardiac arrhythmias in patients with heart failure: a randomized clinical trial. JAMA Intern Med. 2016;176(12):1752–9.CrossRefGoogle Scholar
  11. 11.
    Ding M, Bhupathiraju SN, Satija A, van Dam RM, Hu FB. Long-term coffee consumption and risk of cardiovascular disease: a systematic review and a dose-response meta-analysis of prospective cohort studies. Circulation. 2014;129(6):643–59.CrossRefGoogle Scholar
  12. 12.
    Enriquez A, Frankel DS. Arrhythmogenic effects of energy drinks. J Cardiovasc Electrophysiol. 2017;28(6):711–7.CrossRefGoogle Scholar
  13. 13.
    Svatikova A, Covassin N, Somers KR, et al. A randomized trial of cardiovascular responses to energy drink consumption in healthy adults. JAMA. 2015;314(19):2079–82.CrossRefGoogle Scholar
  14. 14.
    Ali F, Rehman H, Babayan Z, Stapleton D, Joshi DD. Energy drinks and their adverse health effects: a systematic review of the current evidence. Postgrad Med. 2015;127(3):308–22.CrossRefGoogle Scholar
  15. 15.
    Reineck E, Rolston B, Bragg-Gresham JL, et al. Physical activity and other health behaviors in adults with hypertrophic cardiomyopathy. Am J Cardiol. 2013;111(7):1034–9.CrossRefGoogle Scholar
  16. 16.
    Paz R, Jortner R, Tunick PA, et al. The effect of the ingestion of ethanol on obstruction of the left ventricular outflow tract in hypertrophic cardiomyopathy. N Engl J Med. 1996;335(13):938–41.CrossRefGoogle Scholar
  17. 17.
    Xi B, Veeranki SP, Zhao M, Ma C, Yan Y, Mi J. Relationship of alcohol consumption to all-cause, cardiovascular, and cancer-related mortality in U.S. adults. J Am Coll Cardiol. 2017;70(8):913–22.CrossRefGoogle Scholar
  18. 18.
    Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ. 2011;342:d671.CrossRefGoogle Scholar
  19. 19.
    O’Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50(11):1009–14.CrossRefGoogle Scholar
  20. 20.
    Kodama S, Saito K, Tanaka S, et al. Alcohol consumption and risk of atrial fibrillation: a meta-analysis. J Am Coll Cardiol. 2011;57(4):427–36.CrossRefGoogle Scholar
  21. 21.
    Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698):1383–91.CrossRefGoogle Scholar
  22. 22.
    Thomas G, Kloner RA, Rezkalla S. Adverse cardiovascular, cerebrovascular, and peripheral vascular effects of marijuana inhalation: what cardiologists need to know. Am J Cardiol. 2014;113(1):187–90.CrossRefGoogle Scholar
  23. 23.
    Jones RT. Cardiovascular system effects of marijuana. J Clin Pharmacol. 2002;42(11 Suppl):58S–63S.CrossRefGoogle Scholar
  24. 24.
    Franz CA, Frishman WH. Marijuana use and cardiovascular disease. Cardiol Rev. 2016;24(4):158–62.CrossRefGoogle Scholar
  25. 25.
    Gottschalk LA, Aronow WS, Prakash R. Effect of marijuana and placebo-marijuana smoking on psychological state and on psychophysiological cardiovascular functioning in anginal patients. Biol Psychiatry. 1977;12(2):255–66.PubMedGoogle Scholar
  26. 26.
    Mukamal KJ, Maclure M, Muller JE, Mittleman MA. An exploratory prospective study of marijuana use and mortality following acute myocardial infarction. Am Heart J. 2008;155(3):465–70.CrossRefGoogle Scholar
  27. 27.
    Mittleman MA, Lewis RA, Maclure M, Sherwood JB, Muller JE. Triggering myocardial infarction by marijuana. Circulation. 2001;103(23):2805–9.CrossRefGoogle Scholar
  28. 28.
    Reis JP, Auer R, Bancks MP, et al. Cumulative lifetime marijuana use and incident cardiovascular disease in middle age: the coronary artery risk development in young adults (CARDIA) study. Am J Public Health. 2017;107(4):601–6.CrossRefGoogle Scholar
  29. 29.
    Jouanjus E, Lapeyre-Mestre M, Micallef J, French Association of the Regional A, Dependence Monitoring Centres Working Group on Cannabis C. Cannabis use: signal of increasing risk of serious cardiovascular disorders. J Am Heart Assoc. 2014;3(2):e000638.CrossRefGoogle Scholar
  30. 30.
    Bachs L, Morland H. Acute cardiovascular fatalities following cannabis use. Forensic Sci Int. 2001;124(2–3):200–3.CrossRefGoogle Scholar
  31. 31.
    Charbonney E, Sztajzel JM, Poletti PA, Rutschmann O. Paroxysmal atrial fibrillation after recreational marijuana smoking: another “holiday heart”? Swiss Med Wkly. 2005;135(27–28):412–4.PubMedGoogle Scholar
  32. 32.
    Korantzopoulos P, Liu T, Papaioannides D, Li G, Goudevenos JA. Atrial fibrillation and marijuana smoking. Int J Clin Pract. 2008;62(2):308–13.CrossRefGoogle Scholar
  33. 33.
    Sherrid MV. Drug therapy for hypertrophic cardiomypathy: physiology and practice. Curr Cardiol Rev. 2016;12(1):52–65.CrossRefGoogle Scholar
  34. 34.
    Adler A, Fourey D, Weissler-Snir A, et al. Safety of outpatient initiation of disopyramide for obstructive hypertrophic cardiomyopathy patients. J Am Heart Assoc. 2017;6(6).Google Scholar
  35. 35.
    Soukoulis V, Dihu JB, Sole M, et al. Micronutrient deficiencies an unmet need in heart failure. J Am Coll Cardiol. 2009;54(18):1660–73.CrossRefGoogle Scholar
  36. 36.
    Olivotto I, Maron BJ, Tomberli B, et al. Obesity and its association to phenotype and clinical course in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2013;62(5):449–57.CrossRefGoogle Scholar
  37. 37.
    Canepa M, Sorensen LL, Pozios I, et al. Comparison of clinical presentation, left ventricular morphology, hemodynamics, and exercise tolerance in obese versus nonobese patients with hypertrophic cardiomyopathy. Am J Cardiol. 2013;112(8):1182–9.CrossRefGoogle Scholar
  38. 38.
    Ommen SR, Lopez-Jimenez F. Obesity and hypertrophic cardiomyopathy: chickens, eggs, and causality: clinical skills remain the key to caring for patients. J Am Coll Cardiol. 2013;62(5):458–9.CrossRefGoogle Scholar
  39. 39.
    Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Berger PB, Tajik AJ. Adverse prognosis of patients with hypertrophic cardiomyopathy who have epicardial coronary artery disease. Circulation. 2003;108(19):2342–8.CrossRefGoogle Scholar
  40. 40.
    Argulian E, Messerli FH, Aziz EF, et al. Antihypertensive therapy in hypertrophic cardiomyopathy. Am J Cardiol. 2013;111(7):1040–5.CrossRefGoogle Scholar
  41. 41.
    Pedrosa RP, Drager LF, Genta PR, et al. Obstructive sleep apnea is common and independently associated with atrial fibrillation in patients with hypertrophic cardiomyopathy. Chest. 2010;137(5):1078–84.CrossRefGoogle Scholar
  42. 42.
    Eleid MF, Konecny T, Orban M, et al. High prevalence of abnormal nocturnal oximetry in patients with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2009;54(19):1805–9.CrossRefGoogle Scholar
  43. 43.
    Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2343–9.CrossRefGoogle Scholar
  44. 44.
    Pelliccia A, Fagard R, Bjornstad HH, et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26(14):1422–45.CrossRefGoogle Scholar
  45. 45.
    Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. J Am Coll Cardiol. 2005;45(8):2–64.Google Scholar
  46. 46.
    Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e273–80.PubMedGoogle Scholar
  47. 47.
    Mitchell JH, Haskell WL, Raven PB. Classification of sports. J Am Coll Cardiol. 1994;24(4):864–6.CrossRefGoogle Scholar
  48. 48.
    Levine BD, Baggish AL, Kovacs RJ, Link MS, Maron MS, Mitchell JH. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 1: classification of sports: dynamic, static, and impact: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2350–5.CrossRefGoogle Scholar
  49. 49.
    Zipes DP, Link MS, Ackerman MJ, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 9: arrhythmias and conduction defects: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e315–25.CrossRefGoogle Scholar
  50. 50.
    Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol. 2008;52(24):1990–6.CrossRefGoogle Scholar
  51. 51.
    Baggish AL, Ackerman MJ, Lampert R. Competitive sport participation among athletes with heart disease: a call for a paradigm shift in decision making. Circulation. 2017;136(17):1569–71.CrossRefGoogle Scholar
  52. 52.
    Mitten MJ, Zipes DP, Maron BJ, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 15: legal aspects of medical eligibility and disqualification recommendations: a scientific statement from the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e346–9.CrossRefGoogle Scholar
  53. 53.
    Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115(17):2358–68.CrossRefGoogle Scholar
  54. 54.
    HCM Fitness Programs. Accessed 25 Nov 2017, 2017.
  55. 55.
    Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation. 2004;109(22):2807–16.CrossRefGoogle Scholar
  56. 56.
    Saberi S, Wheeler M, Bragg-Gresham J, et al. Effect of moderate-intensity exercise training on peak oxygen consumption in patients with hypertrophic cardiomyopathy: a randomized clinical trial. JAMA. 2017;317(13):1349–57.CrossRefGoogle Scholar
  57. 57.
    Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2012;125(8):1058–72.CrossRefGoogle Scholar
  58. 58.
    Stauffer JC, Ruiz V, Morard JD. Subaortic obstruction after sildenafil in a patient with hypertrophic cardiomyopathy. N Engl J Med. 1999;341(9):700–1.CrossRefGoogle Scholar
  59. 59.
    Awan GM, Calderon E, Dawood G, Alpert MA. Acute, symptomatic atrial fibrillation after sildenafil citrate therapy in a patient with hypertrophic obstructive cardiomyopathy. Am J Med Sci. 2000;320(1):69–71.CrossRefGoogle Scholar
  60. 60.
    Krul SP, van der Smagt JJ, van den Berg MP, Sollie KM, Pieper PG, van Spaendonck-Zwarts KY. Systematic review of pregnancy in women with inherited cardiomyopathies. Eur J Heart Fail. 2011;13(6):584–94.CrossRefGoogle Scholar
  61. 61.
    Stergiopoulos K, Shiang E, Bench T. Pregnancy in patients with pre-existing cardiomyopathies. J Am Coll Cardiol. 2011;58(4):337–50.CrossRefGoogle Scholar
  62. 62.
    Bulletins-Gynecology ACoP. ACOG practice bulletin. No. 73: use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107(6):1453–72.CrossRefGoogle Scholar
  63. 63.
    Silversides CK, Sermer M, Siu SC. Choosing the best contraceptive method for the adult with congenital heart disease. Curr Cardiol Rep. 2009;11(4):298–305.CrossRefGoogle Scholar
  64. 64.
    Pinski SL, Trohman RG. Interference in implanted cardiac devices, Part I. Pacing Clin Electrophysiol PACE. 2002;25(9):1367–81.CrossRefGoogle Scholar
  65. 65.
    Fetter JG, Ivans V, Benditt DG, Collins J. Digital cellular telephone interaction with implantable cardioverter-defibrillators. J Am Coll Cardiol. 1998;31(3):623–8.CrossRefGoogle Scholar
  66. 66.
    Hayes DL, Carrillo RG, Findlay GK, Embrey M. State of the science: pacemaker and defibrillator interference from wireless communication devices. Pacing Clin Electrophysiol PACE. 1996;19(10):1419–30.CrossRefGoogle Scholar
  67. 67.
    Jilek C, Tzeis S, Vrazic H, et al. Safety of screening procedures with hand-held metal detectors among patients with implanted cardiac rhythm devices: a cross-sectional analysis. Ann Intern Med. 2011;155(9):587–92.CrossRefGoogle Scholar
  68. 68.
    Fetter JG, Benditt DG, Stanton MS. Electromagnetic interference from welding and motors on implantable cardioverter-defibrillators as tested in the electrically hostile work site. J Am Coll Cardiol. 1996;28(2):423–7.CrossRefGoogle Scholar
  69. 69.
    Epstein AE, Baessler CA, Curtis AB, et al. Addendum to “Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology”: public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society. Circulation. 2007;115(9):1170–6.CrossRefGoogle Scholar
  70. 70.
    Epstein AE, Miles WM, Benditt DG, et al. Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation. 1996;94(5):1147–66.CrossRefGoogle Scholar
  71. 71.
    Maron BJ, Shen WK, Link MS, et al. Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy. N Engl J Med. 2000;342(6):365–73.CrossRefGoogle Scholar
  72. 72.
    Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation. 2013;127(20):2021–30.CrossRefGoogle Scholar
  73. 73.
    Administration FA. Guide for aviation medical examiners. 2014.Google Scholar
  74. 74.
    Maron BJ, Barry JA, Poole RS. Pilots, hypertrophic cardiomyopathy, and issues of aviation and public safety. Am J Cardiol. 2004;93(4):441–4.CrossRefGoogle Scholar
  75. 75.
    Administration FMCS. Medical examiner handbook. 2014.Google Scholar
  76. 76.
    Defense Do. Directive 6130.03: Medical Standards for Appointment, Enlistment, or Induction in the Military Services. 2011.Google Scholar
  77. 77.
    Hudson KL, Holohan MK, Collins FS. Keeping pace with the times – the genetic information nondiscrimination act of 2008. N Engl J Med. 2008;358(25):2661–3.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Cardiology, Hypertrophic Cardiomyopathy ClinicUniversity of WashingtonSeattleUSA

Personalised recommendations