From the Guidelines
Epinephrine (adrenaline) should be avoided in patients with Hypertrophic Obstructive Cardiomyopathy (HOCM) as it can exacerbate the condition by increasing heart rate and contractility, thereby worsening the obstruction in the left ventricular outflow tract. According to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1, management considerations for patients with HOCM include avoiding hypotension and reduced afterload, as well as avoiding tachycardia to ensure adequate LV filling. The guideline also recommends prioritizing intravenous fluid administration to correct hypovolemia and using alpha-agonists, such as phenylephrine or vasopressin, rather than beta-agonists, which can worsen LVOT obstruction.
Key considerations for managing HOCM include:
- Avoiding medications that increase heart contractility, such as epinephrine
- Maintaining sinus rhythm to prevent decreased LV compliance
- Using beta-blockers and/or nondihydropyridine calcium channel blockers to reduce heart contractility and relieve LVOT obstruction
- Prioritizing intravenous fluid administration to correct hypovolemia and using alpha-agonists to manage hypotension
In situations where vasopressors are required, careful hemodynamic monitoring is essential, and consultation with a cardiologist experienced in HOCM management is advisable, as noted in the guideline 1. The use of transesophageal echocardiography (TEE) can also be considered in situations of hemodynamic instability to evaluate for LVOT obstruction in patients with HCM. Overall, the goal is to avoid exacerbating the dynamic obstruction characteristic of HOCM, and to manage the condition with medications and strategies that reduce heart contractility and promote adequate LV filling.
From the FDA Drug Label
Myocardial ischemia, myocardial infarction and cardiomyopathy have been noted in the literature following overdose of epinephrine. The answer to whether epinephrine can exacerbate Hypertrophic Obstructive Cardiomyopathy (HOCM) is not directly addressed in the label. However, it does mention that cardiomyopathy has been noted in the literature following overdose of epinephrine 2.
- It is possible that epinephrine may worsen cardiomyopathy, including HOCM, especially in cases of overdose.
- However, without direct information, a conservative clinical decision would be to exercise caution when administering epinephrine to patients with HOCM.
From the Research
Epinephrine and Hypertrophic Obstructive Cardiomyopathy (HOCM)
- Epinephrine, also known as adrenaline, is a hormone and neurotransmitter that can increase heart rate and blood pressure.
- There is no direct evidence in the provided studies that epinephrine exacerbates HOCM.
- However, it is known that beta-blockers, which block the effects of epinephrine, are a common treatment for HOCM 3, 4, 5, 6, 7.
- This suggests that epinephrine may potentially worsen symptoms of HOCM, as beta-blockers are used to reduce the heart's workload and prevent obstruction.
- The studies focus on the treatment of HOCM with beta-blockers, calcium channel blockers, and other medications, as well as surgical options such as septal myectomy and alcohol septal ablation 3, 4, 5, 6, 7.
- While the exact effect of epinephrine on HOCM is not directly addressed in the studies, the use of beta-blockers as a treatment suggests that epinephrine may have a negative impact on the condition.
Treatment of HOCM
- Beta-blockers are a first-line treatment for HOCM, and are used to reduce symptoms and prevent obstruction 3, 4, 5, 6, 7.
- Calcium channel blockers, such as verapamil, may also be used to treat HOCM, particularly in patients who do not respond to beta-blockers 3, 4, 5, 6, 7.
- Surgical options, such as septal myectomy and alcohol septal ablation, may be considered for patients with severe symptoms who do not respond to medical therapy 4, 6, 7.