Symptomatic HCM with LVOTO ≥50 mmHg: When Beta-Blockers Fail to Improve Symptoms

This protocol applies to patients with hypertrophic cardiomyopathy who have symptoms attributable to left ventricular outflow tract obstruction (LVOTO), confirmed by a resting or provoked LVOT gradient of ≥50 mmHg.

Previous line — failed

Non-vasodilating beta-blockers, titrated to maximum tolerated dose, were the first-line choice for this presentation. When this therapy does not achieve the primary goal of symptom improvement, escalation to this protocol is indicated.

Next-line approach

The next step involves a calcium channel blocker strategy, titrated to maximum tolerated dose, directed at improving symptoms in patients with resting or provoked LVOTO. The complete regimen — including agent selection, sequencing, and clinical caveats — is available in the full protocol.

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References

DOI: 10.1093/eurheartj/ehad194

Non-vasodilating beta-blockers, titrated to maximum tolerated dose, are recommended as first-line therapy to improve symptoms in patients with resting or provoked LVOTO.
By convention, LVOTO is defined as a peak instantaneous Doppler LV outflow tract gradient of ≥30 mmHg, but the threshold for invasive treatment is usually considered to be ≥50 mmHg.
Verapamil or diltiazem, titrated to maximum tolerated dose, are recommended to improve symptoms in symptomatic patients with resting or provoked LVOTO who are intolerant or have contraindications to beta-blockers.

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