From the Guidelines
Hypertrophic obstructive cardiomyopathy (HOCM) is primarily managed with nonvasodilating beta blockers as first-line therapy, with calcium channel blockers such as verapamil or diltiazem as reasonable alternatives, according to the 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline 1. The goal of pharmacological therapy is symptom relief, as there is no convincing evidence that it alters the natural history of HCM.
- The choice of medication is determined by the patient's symptom response, rather than the measured gradient, due to the variable nature of the outflow tract obstruction throughout daily life.
- For patients who do not respond to beta blockers or calcium channel blockers, advanced therapies such as disopyramide, mavacamten (a cardiac myosin inhibitor), or septal reduction may be considered, as outlined in the 2024 guideline 1.
- It is also crucial to eliminate medications that may worsen outflow tract obstruction, including pure vasodilators like dihydropyridine class calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, as well as high-dose diuretics.
- Low-dose diuretics may be useful in some cases, particularly for patients with persistent dyspnea or congestive symptoms, when added to other first-line medications, as noted in the guideline 1. The management of HOCM should be individualized, taking into account symptom severity, degree of obstruction, and risk stratification, with treatment decisions ideally made at centers experienced in HOCM care, based on the principles outlined in the 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline 1.
From the Research
Management of Hypertrophic Obstructive Cardiomyopathy (HOCM)
The management of HOCM involves several approaches, including:
- Activity restriction with avoidance of volume depletion 2
- Prevention of sudden cardiac death, which may involve the use of an implantable cardioverter-defibrillator (ICD) in high-risk patients 2, 3
- Control of symptoms using pharmacologic treatment, such as:
- Beta blockers, which are proposed for symptomatic patients with no gradient or with a gradient that appears only on exertion 4, 2, 3, 5
- Verapamil, which is used as a second-line drug when beta blockers are insufficient or ineffective, but must be avoided in patients with blockage at rest with severe symptoms 4, 2, 3, 5
- Disopyramide, which is indicated for patients with obstruction who do not respond to beta blockers and/or verapamil 4, 6
- Screening of relatives to identify those who may be at risk of developing HOCM 2
- Septal reduction therapy (SRT), which may be considered for patients with intolerable symptoms despite optimal conservative therapy, and can be performed using either septal myectomy or alcohol septal ablation (ASA) 2, 3, 6
Treatment Options for Symptomatic HOCM
For patients with symptomatic HOCM, treatment options may include:
- Pharmacologic therapy with beta blockers, verapamil, or disopyramide 4, 2, 3, 5, 6
- Septal myectomy, which is usually offered to younger patients with extreme hypertrophy 2, 3
- Alcohol septal ablation (ASA), which is usually directed to older patients or those with important comorbidities 2, 3
- Dual-chamber pacemaker (PM) or ICD, which may be used in patients who have a high risk of sudden cardiac death or who have undergone a trial of pacing with short atrioventricular (AV) delay 2