Algorithm medical therapy for heart failure symptoms in hypertrophic cardiomyopathy

HCM: hypertrophic cardiomyopathy; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; BB: beta blocker; CCB: calcium channel blocker; ASA: alcohol septal ablation.
* Nondihydropyridine CCB monotherapy is sometimes used in patients with contraindications to BB (eg, reactive airway disease) or those who are unable to tolerate BB therapy due to side effects.
¶ Dual therapy with BB and nondihydropyridine CCB may be limited by bradycardia.
Δ UpToDate experts prefer BB and disopyramide as most efficacious in relieving heart failure symptoms in patients with HCM and LVOT obstruction. When initiating disopyramide, the dosing of AV nodal blocking agents can often be reduced.
◊ For some patients, combination therapy with BB and nondihydropyridine CCB may also be tried, but this combination is associated with greater likelihood of bradyarrhythmias or conduction system disease.
§ Prior to initiation of BB therapy, the patient should have no or minimal evidence of fluid retention.
¥ CCBs are generally not indicated in patients with HF and volume overload.
‡ Other therapies for patients with HFrEF, including ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists have not been studied in patients with HCM and symptomatic HFrEF.
† For patients who are candidates for both surgical septal myectomy and alcohol septal ablation, UpToDate suggests surgical septal myectomy performed in a high volume center with expertise with this procedure, based on extensive clinical experience with the procedure, clear clinical efficacy, and the ability to treat concomitant cardiac problems simultaneously.