From the Guidelines
Beta-blockers and calcium channel blockers are the preferred medications for hypertrophic cardiomyopathy (HCM) in African Americans, with a focus on reducing morbidity, mortality, and improving quality of life. Specifically, non-vasodilating beta-blockers like metoprolol (starting at 25-50mg twice daily) or bisoprolol (2.5-5mg daily) are first-line options, as they help reduce heart rate, improve diastolic filling, and decrease left ventricular outflow tract obstruction 1. For those who cannot tolerate beta-blockers, non-dihydropyridine calcium channel blockers such as verapamil (starting at 120mg daily in divided doses) or diltiazem (120-360mg daily) are good alternatives, as they have been shown to provide effective symptomatic relief in patients with HCM 1.
In African American patients with HCM, it is essential to consider the potential benefits of calcium channel blockers, given the higher prevalence of hypertension in this population 1. Additionally, the combination of hydralazine and isosorbide dinitrate may be beneficial in reducing morbidity and mortality in African American patients with heart failure, although this should be considered on a case-by-case basis 1.
When selecting medications for HCM in African Americans, it is crucial to individualize treatment based on symptoms, degree of obstruction, and comorbidities. Regular monitoring of blood pressure, heart rate, and symptoms is essential to adjust dosing appropriately. Patients should avoid dehydration and excessive alcohol consumption, which can worsen symptoms. Consultation with a cardiologist experienced in treating HCM is recommended for optimal management.
Key considerations in managing HCM in African Americans include:
- Using beta-blockers and calcium channel blockers as first-line treatments
- Individualizing treatment based on symptoms and comorbidities
- Regularly monitoring blood pressure, heart rate, and symptoms
- Avoiding dehydration and excessive alcohol consumption
- Considering the potential benefits of calcium channel blockers in African American patients with hypertension
- Consulting with a cardiologist experienced in treating HCM for optimal management 1.
From the Research
Blood Pressure Medications for Hypertrophic Cardiomyopathy in African Americans
- The choice of blood pressure medication for hypertrophic cardiomyopathy in African Americans may be different from other populations, with diuretics being a logical first-line choice for blood pressure reduction 2.
- However, most patients will require combination therapy, and the choice of drugs for combination therapy in African American patients may be different 2, 3.
- Beta blockers and nondihydropyridine calcium-channel blockers have been standard-of-care medications for patients with symptomatic obstructive hypertrophic cardiomyopathy (oHCM) 4, 5.
- Cardiac myosin inhibitors, such as aficamten, have been shown to improve exercise capacity and alleviate symptoms in oHCM when added to standard-of-care medications, and are currently being evaluated as a potential first-line therapy for newly diagnosed oHCM 5.
- Verapamil therapy was not associated with a higher incidence of adverse events than β-blocker therapy in a real-world cohort of low-risk patients with HCM 4.
Considerations for African American Patients
- African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy 2, 3.
- The use of diuretics in African American patients may be a logical first-line choice for BP reduction, but the responsiveness to monotherapy with ACE inhibitors, angiotensin receptor blockers, and beta blockers may be less than the responsiveness to diuretics and calcium channel blockers 3.
- The choice of drugs for combination therapy in African American patients may be different, and the primary means of prevention and early treatment of hypertension in African Americans will be the appropriate use of lifestyle modification 3.
Ongoing Research
- The MAPLE-HCM study is ongoing to evaluate aficamten as both first-line therapy for newly diagnosed oHCM and as a monotherapy alternative for patients currently on standard-of-care drugs 5.
- The study aims to fill the evidence gap by evaluating aficamten as a potential first-line therapy for newly diagnosed oHCM, and to compare its efficacy and safety to metoprolol succinate in adults with symptomatic oHCM 5.