From the Guidelines
The initial treatment for Hypertrophic Obstructive Cardiomyopathy (HOCM) typically involves beta-blockers as first-line therapy. Medications such as metoprolol (25-100 mg twice daily), atenolol (25-100 mg daily), or propranolol (10-40 mg three to four times daily) are commonly prescribed 1. These medications work by reducing heart rate, contractility, and left ventricular outflow tract obstruction, thereby improving symptoms such as chest pain, shortness of breath, and syncope. They also decrease myocardial oxygen demand and improve diastolic filling.
Key Considerations
- Patients should avoid dehydration, excessive alcohol, and strenuous exercise, particularly activities involving Valsalva maneuvers.
- Regular follow-up with a cardiologist is essential to monitor symptoms and adjust medication dosages.
- For patients with persistent symptoms despite optimal medical therapy, more invasive options like septal reduction therapy (surgical myectomy or alcohol septal ablation) may be considered.
- Vasodilators, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and dihydropyridine calcium channel blockers, should be discontinued as they can worsen symptoms caused by dynamic outflow tract obstruction 1.
- Alternative medications like disopyramide or cardiac myosin inhibitors (e.g., mavacamten) may be considered for patients who do not respond to first-line therapy 1.
Medication Management
- Beta-blockers should be titrated to a dose where symptom benefit is observed, but failure of beta-blockade should not be declared until demonstrated physiologic evidence of beta-blockade (e.g., suppression of resting heart rate) is reported 1.
- Non-dihydropyridine calcium channel blockers like verapamil or diltiazem may be used if beta-blockers are not tolerated or insufficient.
- Disopyramide has been shown to provide symptomatic benefit in patients with obstructive HCM who have failed first-line therapy, but it should be used in combination with another medication that has atrioventricular nodal blocking properties 1.
From the Research
Initial Treatment for Hypertrophic Obstructive Cardiomyopathy (HOCM)
The initial treatment for HOCM involves several key components:
- Activity restriction with avoidance of volume depletion 2
- Prevention of sudden cardiac death 2
- Control of symptoms 2
- Screening of relatives 2
Pharmacologic Treatment
Pharmacologic treatment of symptoms in patients with HOCM consists of:
- Negative inotropic drugs, namely beta blockers 2, 3, 4
- Disopyramide 2, 3, 5
- A nondihydropyridine calcium channel blocker (CCB), usually verapamil 2, 4, 5
Septal Reduction Therapy
For patients with intolerable symptoms despite optimal conservative therapy, septal reduction therapy (SRT) should be considered 2, 6:
- Septal myectomy: usually offered to younger patients with extreme hypertrophy 2, 6
- Alcohol septal ablation (ASA): usually directed to older patients, and those with important comorbidities 2, 6
Invasive Therapies
Invasive therapies for symptomatic obstructive hypertrophic cardiomyopathy include: