What is the treatment for Hypertrophic Obstructive Cardiomyopathy (HOCM) in the United Kingdom (UK)?

From the Guidelines

Hypertrophic obstructive cardiomyopathy (HOCM) in the UK is treated through a stepwise approach, beginning with medications and progressing to more invasive options when necessary, with the primary goal of alleviating symptoms and improving quality of life, as recommended by the European Society of Cardiology guidelines 1.

Treatment Approach

The treatment approach for HOCM involves:

• First-line treatment with beta-blockers such as bisoprolol (2.5-10mg daily) or metoprolol (25-200mg daily) to reduce heart rate, contractility, and outflow obstruction, as they are the mainstay of pharmacologic therapy and have been shown to alleviate symptoms of exertional dyspnea, palpitations, and chest discomfort 1.
• If beta-blockers are ineffective or not tolerated, non-dihydropyridine calcium channel blockers like verapamil (120-480mg daily) may be used, as they have been shown to provide effective symptomatic relief in some patients 1.
• Disopyramide (300-800mg daily in divided doses) can be added for persistent symptoms, as it has been shown to be effective in ameliorating symptoms in patients with obstructive HCM 1.

Invasive Procedures

For those with refractory symptoms despite optimal medical therapy, invasive procedures are considered, including:

• Alcohol septal ablation, which involves injecting alcohol into the septal branch of the left anterior descending artery to induce a controlled infarction, as it has been shown to be effective in reducing symptoms and improving quality of life in selected patients 1.
• Surgical myectomy to remove part of the thickened septum, which is considered the preferred treatment for most patients who meet the core selection criteria, as it has been shown to be effective in abolishing outflow obstruction and improving symptoms in patients with severe symptoms unresponsive to medical therapy 1.

Additional Considerations

• Implantable cardioverter-defibrillators (ICDs) are recommended for patients at high risk of sudden cardiac death, as they have been shown to be effective in preventing sudden cardiac death in patients with HOCM 1.
• All patients require regular cardiology follow-up with echocardiography, and genetic counseling is advised for family members due to the hereditary nature of the condition, as it is essential for early detection and management of the condition in family members 1.
• Treatment decisions are typically made by specialized cardiomyopathy teams in tertiary centers following the European Society of Cardiology guidelines, which are adopted in UK practice, to ensure that patients receive optimal care and management of their condition 1.

From the Research

Treatment Options for Hypertrophic Obstructive Cardiomyopathy in the UK

• The treatment of hypertrophic obstructive cardiomyopathy (HOCM) in the UK involves several approaches, including pharmacological and surgical interventions 2, 3, 4, 5, 6.
• Pharmacological therapy is the first-line treatment, with beta-blockers and non-dihydropyridine calcium channel blockers being commonly used to reduce symptoms and left ventricular outflow tract (LVOT) gradients 4, 6.
• For patients who remain symptomatic despite initial pharmacological therapy, further treatment options include disopyramide, surgical myectomy, and alcohol septal ablation 6.
• Surgical myectomy is considered the gold standard for eliminating subaortic obstruction, with a significantly lower complication rate and more complete and lasting reduction of LVOT obstruction compared to percutaneous ablation 5.
• Novel treatments, such as dual-chamber pacing and radiofrequency catheter ablation, are also being explored for the management of HOCM 2.
• A patient-centric approach is key to optimal management, taking into account individual patient preferences, needs, and beliefs, as well as phenotypes and risk stratification 3.

Surgical Interventions

• Surgical myectomy is a proven safe and effective treatment for HOCM, with a low complication rate and significant reduction in LVOT obstruction 5, 6.
• Alcohol septal ablation is also a viable option for patients who are not suitable for surgical myectomy or prefer a less invasive approach 2, 6.
• The choice of surgical intervention depends on individual patient factors, including the severity of symptoms, LVOT gradient, and overall health status.

Future Perspectives

• New therapies, such as myosin inhibitors, are being developed and introduced into clinical practice, offering promising future treatment options for HOCM 4.
• Gene therapies are also being explored, with the potential to revolutionize the management of HOCM 3.
• Further research is needed to fully understand the efficacy and safety of these novel treatments and to optimize patient outcomes.