In severe cases I use the association of both drugs. In cases of moderate or mild hypertrophy I prefer beta blockers, if there isn't contraindications.
Beta blockers are ideal, they increase the diastole thereby increase the LV filling and the preload and decrease the myocardial contractility; both the actions - increase in preload and decrease in myocardial contractility tends to prevent left ventricle outflow tract obstruction
The first-line therapy for symptomatic HCM is beta-blockers. Like Neema sad above: by decreasing contractile force, beta-blockers decrease the LVOT gradient as well as reduce overall myocardial workload and oxygen demand.More: raise diastolic filling by slowing the heart rate and allowing for more passive filling of the LV. For second-line therapyf the calcium-channel blockers (specifically nondihydropyridine, i.e., verapamil) with their negative chronotropic effect, leads to increased diastolic relaxation time (thus increasing preload). Determine when using first, second line or the two drugs at the same time is a challenge including intolerance or impending use (asthma, AV conduction disturbance for example) and grading the clinical frame of each individualized patient..
I agree with both statements above. Additionaly, resting heart rate 50-60/min seems to be reasonable to achieve a clinically significant improvement of symptoms.
I agree, BB is my treatment of choice. Verapamil or diltiazem may be utilised in patients with asthma.
I think the next question that should be explored is when to refer these patients for surgical management?
I agree with BB first and CCB (non-dihydropyridine second). I think that the real next question is not so much surgical intervention, but rather who gets an ICD - bearing in mind the rather high rate of inappropriate ICD discharge in this group (about 25% per year). I would reserve surgical intervention for the group with intractable LVOT obstruction + symptoms - and would never advise alcohol septal ablation as it's too hard to control and potentially very pro-arrhythmic.
Indeed the question is about drugs, prevention of threatening arrhythmias are a great concern in hypertrophic myocardiopathy. To ICD five situations allows the device 1. Ressuscitated SCD, previous sustained VT or documented NSTV on 24 hours HOLTER, Ventricular Fibrilation 2. Famíly history of SCD 3. Unexplained syncope 4.
Inotropic deficit in stress resting 5. Wall thickness of Left Ventricle 30 mm or more.
About surgery: there's a place and time to do it. But this in specially centers with dedicated and experient team on this field.
Beta-blocker is the drug of choice for patients with HCM (for all reasons stated above) and symptoms, especially in patients with significant left ventricular obstruction. Verapamil can be used in selected patients without obstruction in case the beta blocker is contraindicated or not tolerated but with absolute caution (if at all) in patients with possible labile obstruction and high pulmonary arterial pressure.
The discussion about further treatment depends on symptomatic status and risk of sudden cardiac death. The former is sometimes difficult to realise, especially in young patients who have grown up with the disease. Cardiopulmonary exercise test may help. Treatment with the above mentioned drugs (as well as disopyramide for patients with obstruction) or with septal reduction therapy (alcohol septal ablation or myectomy) is meant for patients with symptoms. There are still no firm data that septal reduction therapies may reduce the risk of sudden death.
Sudden death risk is independent of symptoms and can be estimated for primary prevention through a number of clinical risk factors (family history of SCD, nonsustained ventricular tachycardia, unexplained syncope, abnormal blood pressure response at exercise and extreme wall thickness >30 mm). A latest approach uses also age, fractional shortening, left atrial diameter and maximal gradient (O'Mahony C, et al. Eur Heart J 2013 Oct 14;epub ahead of print).
The decision for an ICD is difficult - sudden death is devastating but complications or inappropriate ICD responses occur in about 30% of young patients.
I agree with Dr. Rigopoulos. However, it is probably much higher rate of ICD complications. In the only multicenter study in HCM pts
beta-Bl. = 1st choice. Verapamil works as well, but with V. it should be kept in mind that some patients may respond paradoxically, i.e. obstruction may worsen. Initiation of V.-treatment therefore should be monitored by Echo-Doppler
Medical therapy is important. Interestingly, there are no good RCTs supporting BB or verapamil... But still, the main current issue seems to be indication for ICD. I feel that current criteria are not sufficient.
in my opinion we should differentiate between hypertrophic cardiomyopathy with and without heart failure. In the first case, verapamil is the first line therapy, beta blockers are preferred in the other
my choose is the association with both : beta blocker and channel calcium antagonist ( diltiazem). when the cardiac frequence is between 50-60, I control with echoca
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