HCM Treatment: The View from OHSU

If you are looking for a good survey of current practices in the treatment of HCM, a recent article published in the journal Structural Heart by Dr. Ahmad Masri and the team at Oregon Health and Sciences University (OHSU) provides an informative overview of thirty controversies and considerations in the treatment of HCM. This article explains in some detail how the doctors at this HCM Center approach these situations. 

This article, along with the brand new 2020 AHA/ACC HCM Guidelines, will tell you everything there is to know about the contemporary treatment of HCM.  For a short summary of all things HCM, you can also visit the page on this website entitled “Hypertrophic Cardiomyopathy-HCM for Short.”

 

SCREENING OF HCM FAMILY MEMBERS:

Question:  How often should HCM family members be screened?

Answer: Every 3 years

Question: Do children under 12 need to be screened?                               

Answer: Yes

Question:  How often should cardiac MRI be repeated?

Answer: Every 3 – 5 years

Question: Do gene negative relatives need further screening?

Answer: No, but as new HCM-causative genes are discovered, repeat screening may be necessary.

 

OTHER COMPLEX ISSUES ADDRESSED IN THIS SECTION:

  • What is the utility of cardiopulmonary exercise testing?

  • What are the implications of HCM genotype?

  • What are the clinical implications of obstruction?

  • Are deformation imaging and strain analysis meaningful on echocardiogram? 

QUESTIONS ABOUT DRUGS USED  IN HCM TREATMENT:

Question: Can disopyramide (Norpace) be started on outpatient basis?

Answer: Yes, with an EKG performed one week afterward.

Question:  Is ranolazine (Ranexa) useful in HCM?

Answer: Yes, for angina.

 

OTHER COMPLEX ISSUES ADDRESSED IN THIS SECTION:

  • Are anticoagulants needed in HCM patients with apical aneurysm?

  • Are anti-arrhythmics drugs useful in the treatment of HCM?

RISK STRATIFICATION (OR WHO NEEDS AN ICD?):

Question: Which is the best risk stratification model to use?

Answer: ACC/AHA Model

Question: Is non-sustained ventricular tachycardia a risk factor?

Answer: Yes, can provide added support for ICD, but needs to be evaluated with other risk factors.

Question: How often is it necessary to do ambulatory EKG monitoring for ICD risk assessment?

Answer: Yearly

Question: Should apical aneurysm be a risk factor?

Answer: Yes

 

OTHER COMPLEX ISSUES ADDRESSED IN THIS SECTION:

ELECTROPHYSIOLOGY ISSUES IN HCM

Question: Is rhythm control better than rate control for atrial fibrillation in HCM patients?

Answer: Yes

Question: Is the S-ICD a good option for HCM patients?

Answer: Yes, it can be, especially for younger patients who do not need pacing.

Question: Should patients at lower risk of sudden death with A-V block get a pacemaker or ICD?

Answer: Pacemaker is fine if ICD not otherwise warranted.

Question: Is there a role for the CHA2DS2-VASc score for HCM patients with atrial fibrillation?

Answer: No. HCM patients with Afib should be on anticoagulation regardless of their CHA2-VASc score.

 

OTHER COMPLEX ISSUES ADDRESSED IN THIS SECTION:

  • What is the role of ventricular tachycardia ablation in HCM?

  • Is catheter ablation preferable to anti-arrhythmic drugs in atrial fibrillation?

MANAGEMENT OF PATIENTS WHO DON’T RESPOND TO MEDICATION:

Question:  Which is preferable, myectomy or alcohol septal ablation?

Answer: Highly dependent on patient’s individual circumstances.

Question:  Should additional surgical procedures be used to reduce outflow tract obstruction and systolic anterior motion of the mitral valve?

Answer: Highly dependent on patient’s individual circumstances.

Question:  Are there any clinical consequences resulting from left branch bundle block after myectomy?

Answer: No

Question:  Should transapical myectomy be a treatment option?

Answer: Yes, although this is a rare surgery and should be performed at a center with specific expertise.

Question: What is the role of the mitral valve repair via MitraClip in HCM?

Answer:  This procedure is currently reserved for those who are not able to undergo myectomy or alcohol septal ablation.

Click here to access the entire article.

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