From the Guidelines
Hypertrophic obstructive cardiomyopathy (HOCM) in the UK is treated through a stepwise approach starting with medications, followed by more invasive options if needed, as recommended by the most recent guidelines 1. The treatment approach typically begins with first-line medications, including beta-blockers such as bisoprolol (typically 2.5-10mg daily) or metoprolol (25-200mg daily) to reduce heart rate and contractility, thereby decreasing outflow obstruction. Non-dihydropyridine calcium channel blockers like verapamil (120-480mg daily) are alternatives for those who cannot tolerate beta-blockers. Disopyramide (100-300mg three times daily) may be added for persistent symptoms. Patients should avoid dehydration, excessive alcohol, and vasodilators which can worsen obstruction, as suggested by general lifestyle considerations for patients with hypertrophic cardiomyopathy 1. If medications fail, invasive treatments include alcohol septal ablation or surgical myectomy to reduce the thickened septum. Patients with high risk of sudden cardiac death may receive an implantable cardioverter-defibrillator. Management is typically coordinated through specialized inherited cardiac conditions clinics with regular monitoring including ECGs, echocardiograms, and exercise testing. Genetic testing and family screening are also important components of care as HOCM has a strong hereditary component. Key considerations in the selection of patients for invasive therapies include the presence of symptoms attributable to LVOT obstruction that are refractory to optimal pharmacologic therapy, and maximal instantaneous gradients of at least 50 mm Hg at rest or with physiologic provocation 1. Surgical septal myectomy is considered the preferred treatment for most patients who meet these criteria, with a low operative mortality and high success rate in reducing outflow obstruction and improving symptoms 1.
From the Research
Treatment Options for Hypertrophic Obstructive Cardiomyopathy in the UK
- The treatment of hypertrophic obstructive cardiomyopathy (HOCM) in the UK involves a multidisciplinary approach, including medical, surgical, and interventional management 2.
- Patients with HOCM are typically classified based on the presence of a left ventricular outflow tract (LVOT) gradient at rest or during provocation 2.
- Management of HOCM encompasses activity restriction, prevention of sudden cardiac death, control of symptoms, and screening of relatives 2.
Medical Management
- Pharmacologic treatment of symptoms in patients with HOCM consists of negative inotropic drugs, such as beta blockers, and disopyramide 2.
- A nondihydropyridine calcium channel blocker (CCB), usually verapamil, may be used in patients with noncardiac side-effects of beta blockers 2.
- Beta-blockers alleviate dyspnea and improve patients' quality of life, while verapamil can increase physical resilience 3.
- Mavacamten, a myosin inhibitor, has also been approved for use in Germany and lowers the LVOT gradient and improves quality of life 3.
Surgical and Interventional Management
- Septal reduction therapy (SRT) should be considered for patients with intolerable symptoms despite optimal conservative therapy 2.
- SRT can be performed using septal myectomy or alcohol septal ablation (ASA), with the choice of procedure depending on the patient's age, comorbidities, and preferences 2, 4.
- Dual-chamber pacing and radiofrequency catheter ablation are also available as treatment options for HOCM 4.
- Patient selection for the procedure is crucial, and a balanced discussion of the benefits and risks of each procedure should be had with the patient 2, 4.
Personalized Approach to Management
- A patient-centric approach is key to optimal management of HOCM, taking into account the patient's preferences, needs, and beliefs 5.
- The treatment of HOCM should be individualized based on functional status, comorbidities, local expertise, and patient preference 6, 5.
- Future perspectives in HOCM management include new drugs and gene therapies, which may offer additional treatment options for patients with HOCM 5.