Management

Consult expert advice.

• angina and shortness of breath can be treated with beta blockers e.g. atenolol
  
  
• arrythmias may be treated, and prevented, with amiodarone; digoxin is contraindicated for atrial fibrillation in HOCM
  
  
• if there is paroxysmal AF then the patient should be anticoagulated
  
  
• outflow obstruction may respond to negative ionotropic drugs such as beta-blockers, verapamil and disopyramide
  
  
• patients with outflow tract gradients are at the risk of development of infective endocarditis and are treated with prophylactic antibiotics
  
  
• the patient should be told that he is at risk of sudden death
  
  
• surgical options include myectomy or myotomy with the goal of forming gutter through the outflow obstruction. Also obstruction can be treated via alcohol-induced infarction via a coronary artery catheter (1)

The use of an implantable cardioverter defibrillator should be considered (2)

Exercise and HOCM (3)

• HOCM is the most frequently cited cause of exercise-related sudden cardiac death (SCD) in young individuals and has claimed the lives of some high-profile athletes
  • the circumstantial link between exercise and SCD from HOCM has resulted in conservative exercise recommendations which focus on activities that should be avoided rather than the minimal amount of physical activity required to reap the multiple rewards of exercise
  • consequently, most patients with HOCM are confined to a sedentary lifestyle through fear of SCD, with accruing risk factors such as obesity and low cardiorespiratory fitness that confer a worse prognosis.
  • evidence has shown that recent exercise programmes in asymptomatic and symptomatic individuals with HOCM have shown that mild and moderate exercise is safe and accompanied by increased functional capacity and improved quality of life
    • population studies also reveal that individuals with HCM in the higher quartiles of self-reported physical activity have lower total cardiovascular mortality compared with those in the lower quartiles
  • the impact of vigorous exercise on the natural history of HOCM is unknown, although current experience suggests that affected adults with mild morphology and absence of high-risk factors may partake in such activity without adverse events

Notes:

• in patients without obstruction, treatment is more empirical, including beta-blockers, calcium antagonists and judicious use of diuretics (1)

Reference:

1. Pulse (May 28th 2005): 54-61.
2. NICE (September 2000). Implantable cardioverter defibrillators for arrhythmias.
3. Gati S, Sharma S.Exercise prescription in individuals with hypertrophic cardiomyopathy: what clinicians need to know.Heart Published Online First: 23 February 2022. doi: 10.1136/heartjnl-2021-319861