What is the treatment for Hypertrophic Obstructive Cardiomyopathy (HOCM)?

From the Guidelines

The treatment for Hypertrophic Obstructive Cardiomyopathy (HOCM) should prioritize symptom relief and prevention of complications, with first-line medical therapy including beta-blockers, non-dihydropyridine calcium channel blockers, and disopyramide, as well as consideration of new agents like mavacamten, a cardiac myosin inhibitor, as stated in the 2024 guidelines 1.

Key Considerations

• The primary goal of treatment is to alleviate symptoms, prevent complications, and improve quality of life, with a focus on individualized care based on symptom severity, degree of obstruction, cardiac anatomy, and patient preferences.
• Beta-blockers, such as metoprolol or propranolol, are typically the first-line treatment to reduce heart rate, contractility, and outflow obstruction, as recommended by the guidelines 1.
• Non-dihydropyridine calcium channel blockers like verapamil may be used as an alternative or in addition to beta-blockers for symptom management, as suggested in the guidelines 1.
• Disopyramide can be added for persistent symptoms due to its negative inotropic effects, and new agents like mavacamten offer additional options for patients with obstructive HCM, as noted in the guidelines 1.
• Invasive septal reduction therapies, such as surgical myectomy or alcohol septal ablation, and implantable cardioverter-defibrillators (ICDs) for high-risk patients, are also important considerations in the management of HOCM, as outlined in the guidelines 1.

Additional Recommendations

• Patients should avoid dehydration, excessive alcohol, and strenuous exercise, particularly activities involving sudden bursts of exertion, to prevent worsening of symptoms.
• The elimination of medications that may promote outflow tract obstruction, such as pure vasodilators and high-dose diuretics, is also crucial in managing symptomatic, obstructive HCM, as stated in the guidelines 1.
• Low-dose diuretics may be useful for patients with persistent dyspnea or congestive symptoms when added to other first-line medications, as suggested in the guidelines 1.
• The principles of pharmacological management apply to patients with obstruction at the midventricular level, and careful consideration of the patient's specific condition and needs is essential in developing an effective treatment plan, as emphasized in the guidelines 1.

From the Research

Treatment Options for Hypertrophic Obstructive Cardiomyopathy (HOCM)

• The initial therapy for symptomatic patients with obstruction is medical therapy with β-blockers and calcium antagonists 2.
• For patients with severe symptoms unresponsive to medical therapy, septal reduction therapy, either surgical septal myectomy or alcohol septal ablation, can be effective 2, 3.
• Surgical myectomy is highly effective with a >90% relief of obstruction and improvement in symptoms, and a perioperative mortality rate of <1% 2.
• Alcohol septal ablation is a less invasive treatment with comparable hemodynamic and clinical results to septal myectomy in many patients 2, 4.
• The choice between septal myectomy and alcohol septal ablation depends on patient preference and the availability and experience of the operator and institution 2.

Invasive Therapies for HOCM

• Invasive therapies, including surgical correction of the LVOT obstruction or percutaneous alcohol septal ablation, are options for patients with severe obstruction or symptoms refractory to medical therapy 3.
• Surgical intervention may be required for patients who do not respond to pharmacological and/or interventional treatment 5.
• The primary goal of surgical techniques is to relieve LVOT obstruction, avoid the occurrence and/or recurrence of systolic anterior movement (SAM) of the anterior mitral leaflet (AML), and reduce mitral valve (MV) regurgitation if present 5.

Considerations for Treatment

• The configuration of LVOT obstruction and the presence of mitral valve regurgitation should be considered when selecting a treatment strategy 5, 6.
• Minimally invasive access with subaortic LVOT myectomy and complete resuspension of the AML may be a viable option for treating HOCM and MV regurgitation 5.
• A randomized controlled trial is needed to compare the effectiveness of alcohol septal ablation and surgical myectomy 4.