Obstructive hypertrophic cardiomyopathy (oHCM) is a progressive condition that can worsen over time. So at some point, you might need to make adjustments to your treatment plan to keep your symptoms under good control.
Knowing when it’s time to talk with your cardiologist can sometimes be tricky though. You might not notice gradually worsening symptoms or the fact that you’ve slowly started to limit activities that once felt easy or doable. Use these questions as a guide to help you understand your other options and to decide whether to bring up treatment changes with your cardiologist.
1. Do My Symptoms Mean My Treatment Isn’t Working?
The goal of oHCM treatment is for you to be able to carry out your regular activities and do mild to moderate exercise with relative ease. Ideally, that means little to no shortness of breath, chest pain, or lightheadedness while you’re exerting yourself or while you’re at rest.
If these sorts of symptoms start to creep up — or you notice that you aren’t able to do some of the things that you used to be able to do — you should let your doctor know. “These indicate that a patient’s treatment plan requires reconsideration, especially if these symptoms interfere with his or her quality of life,” says Padma Shenoy, MD, a cardiologist with Manhattan Cardiology in New York City.
2. What Other Medications Are Available?
Cardiologists typically recommend starting with the most conservative option and stepping up therapy as needed if those options aren’t working. So if you’re not getting good symptom relief from your current medication, you can move on to something more potent.
For most people, it looks something like this.
- Start with a non-vasodilating beta-blocker and increase the dose as needed. Metoprolol (Lopressor, Toprol XL) is the most common option, but there are many others.
- If that’s not effective, try a non-dihydropridine calcium channel blocker like verapimil (Verelan) or diltiazem (Cardizem, Tiazac) instead.
- Add a cardiac myosin inhibitor like mavacamten (Camzyos) or aficamten (Myqorzo), or the antiarrhythmic disopyramide (Norpace) if you still aren’t getting good symptom control
Each of these medications comes with its own pros and cons. You and your cardiologist can talk about your individual symptoms and treatment goals to decide on the best therapy.
3. Is There an Option That Has Fewer Side Effects?
It’s not uncommon to have side effects like fatigue, dizziness, or low blood pressure or heart rate when taking a beta-blocker or calcium channel blocker. If these symptoms are making it harder for you to do your daily activities, let your doctor know. There’s usually a way to adjust your treatment plan so you can feel more comfortable.
“With an expanding range of options, including the growing use of cardiac myosin inhibitors, it is often possible to adjust dosing, switch medications, or combine therapies to improve tolerability,” says Behram Mody, MD, the director of the hypertrophic cardiomyopathy program at UCI Health in Orange, California.
4. Are There New Drugs or Clinical Trials I May Be a Candidate For?
Approved in 2022 and 2025, the cardiac myosin inhibitors mavacamten (Camzyos) and aficamten (Myqorzo) are the first medications designed to treat the underlying cause of oHCM, and they’ve been shown to be more effective than options like beta-blockers or calcium channel blockers.
That said, most insurance companies want to see that you’ve tried and failed those more conservative therapies before you can get a myosin inhibitor approved, says Natalie Tapaskar, MD, a cardiologist specializing in hypertrophic cardiomyopathy at UT Southwestern Medical Center in Dallas.
Clinical trials can be another route if you’ve tried a myosin inhibitor without success or if you’re not a candidate for one. If you’re interested in pursuing a trial, talk it over with your cardiologist. “These trials should be part of a carefully personalized treatment plan for each eligible patient based on their clinical picture,” Dr. Shenoy says. You can search for trials at ClinicalTrials.gov.
5. How Will I Know if the New Treatment Is Working?
Fewer symptoms is a good sign. “If a treatment plan is working, patients usually notice improvement in their symptoms of shortness of breath, chest pain, and fatigue, within the first few weeks,” Shenoy says. On the other hand, it may be a few months before you notice an improvement in your tolerance for daily activities or exercise. That’s because it takes time to build up your cardiovascular endurance if you’ve been limiting your activities or avoiding exercise because of your symptoms, she says.
Let your cardiologist know if you aren’t seeing those kinds of positive changes. You can talk about making additional changes to your treatment plan to give you the relief you need.
6. Should We Consider Surgery?
Septal myectomy, an open-heart surgery that completely removes the thickened portion of your heart, “is considered the gold standard,” says Lu Chen, MD, a cardiac electrophysiologist at MemorialCare Heart and Vascular Institute at Orange Coast Medical Center in Fountain Valley, California. Septal ablation is a minimally invasive alternative that’s often used for people who are older or higher risk. Your care team will help you decide which procedure is a better fit for you based on your age, overall health, and treatment goals.
7. Do I Need an ICD?
The small, battery powered device, which is implanted under your skin, doesn’t address symptoms like shortness of breath or chest pain. Instead, it works in the background to continuously monitor your heart rate and correct any irregularities. Dr. Chen compares it to a seat belt: “If the heart gets into an accident [from an irregular heart rhythm], the defibrillator is designed to detect such abnormality and either pace or shock the heart out of the fast heart rhythm,” she says.
8. Are There Other Things I Should Be Doing to Improve My Symptoms?
The Takeaway
- oHCM is a progressive condition; new or worsening symptoms, or the need to cut back on activities you once handled easily, can signal that it’s time to revisit your treatment plan with your cardiologist.
- Treatment typically follows a step-up approach from beta-blockers to stronger options like calcium channel blockers or newer cardiac myosin inhibitors if symptoms aren’t well controlled.
- If medication side effects like fatigue or dizziness are interfering with daily life, your doctor can often adjust your medication, switch therapies, or combine treatments to improve tolerability.
- Options for persistent symptoms include procedures like septal myectomy or ablation, or participation in a clinical trial.
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