A Review of Multimodal Treatment Approach in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is often associated with left ventricular outflow tract (LVOT) obstruction, which affects a substantial proportion of patients. This obstruction results from a range of anatomical abnormalities involving both the valvular and subvalvular structures. Pharmacological therapies play a pivotal role in the management of LVOT obstruction, with a range of drug classes exhibiting distinct mechanisms of action. Beta-blockers, including atenolol and nadolol, are considered the first-line treatment due to their ability to reduce heart rate, myocardial contractility, and enhance diastolic filling. Non-dihydropyridine calcium channel blockers, such as verapamil and diltiazem, are utilized as second-line agents when beta-blockers are ineffective or contraindicated. These agents inhibit calcium influx and improve diastolic function. Disopyramid, a Class 1A antiarrhythmic agent, is employed for patients who do not respond to initial therapeutic interventions and can reduce LVOT gradients. Recent advancements in cardiac myosin modulators, such as Mavacamten and Aficamten, offer targeted therapies by modulating myosin-actin interactions to reduce LVOT gradients and improve symptoms, with promising results from clinical trials. Although gene therapy is still in its nascent stages, it has the potential to address the genetic basis of HCM by employing techniques such as genome editing, gene replacement, and modulation of signaling pathways. Despite the encouraging developments in these fields, further research is necessary to optimize the clinical application of these therapies. For patients exhibiting severe symptoms or demonstrating unresponsiveness to medical treatment, invasive therapies, such as septal reduction therapy (SRT) and alcohol septal ablation (ASA), are considered. SRT, which involves surgical myectomy, offers a comprehensive solution by addressing anatomical anomalies, while ASA provides a less invasive option with similar gradient reduction outcomes. This review aims to provide an overview of current pharmacological and invasive strategies, as well as emerging therapies, in the management of HCM.