Medical management of hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a genetically determined myocardial disease in which symptoms are driven not simply by ventricular hypertrophy, but by a combination of dynamic left ventricular outflow tract obstruction (LVOTO), impaired diastolic filling and other factors.The therapy for HCM differs fundamentally from routine heart failure management and must be mechanism based. In obstructive HCM, the pharmacologic objective is to blunt hypercontractility, lengthen diastole, preserve loading conditions, and reduce the LVOT gradient. In non-obstructive HCM, management is focused on symptom control, heart-rate moderation, careful volume management, and treatment of arrhythmias and congestion. Non-vasodilating beta-blockers, non-dihydropyridine calcium-channel blockers, and disopyramide have constituted the foundation of medical therapy. The contemporary era has added sarcomere-directed treatment with cardiac myosin inhibitors, particularly mavacamten and aficamten, The present review provides a pragmatic algorithm for publication-level clinical use in contemporary practice.