Goals of Treatment in Symptomatic oHCM

Anjali Owens, MD: So let's move into our treatment segment for obstructive HCM [hypertrophic cardiomyopathy]. Michelle, I'll start with you. What is the goal of pharmacologic treatment for patients with symptomatic obstructive HCM?

Michelle M. Kittleson, MD, PhD: I'm glad you gave me an easier question than you gave Andrew or Milind I got off there. So because of the wisdom provided by my co-panelist, we're going to assume for this question that we are certain this is true, obstructive HCM, a left ventricular outflow tract obstruction dynamic related to hypertrophic cardiomyopathy. What do you do with the patient? Well, as we talked about, it's critically important in the diagnosis to define whether your patient has obstruction or not and confirm it's from the hypertrophic cardiomyopathy. Now, assuming you've done that, the next thing you do is look at the patient. Isn't that wonderful? In medicine, it always goes back to the patient because, say, the patient feels amazing. They feel like 1,000,000 bucks they lived their life. They'd never know they had a problem unless you told them. Because they came to you, because someone heard a murmur. They had an abnormal ECG [electrocardiogram]. They're getting some screening. So if you have any symptomatic LVOT obstruction, you can convince yourself based on your history and or an objective measure like a stress test, that they are truly asymptomatic you. Let them live their life.

On the other hand, if they have symptomatic obstructive HCM, then you need to treat them and important curl about treatment is it doesn't matter what the gradient is once you've established the gradient is there, you do not titrate treatment to the gradient because the gradient is by definition dynamic. You titrate it to the patients symptoms. What are we? Like to start with, we like to start with beta blockers, tried and true. I think that might be coming up. I'm not going to steal Andrew's thunder, but I'll say when the goal of the pharmacologic treatment is number one is an obstruction, there is the obstruction from HCM is the obstruction symptomatic and if so, the goal of the pharmacologic management is to make the symptoms better. So you titrate the therapy to the symptoms, not.

Milind Desai, MD, MBA: I'm going to make one comment. Michelle, Anjali, hopefully if you have if you bear with me is symptoms can be deceivingly misleading. So for me, if I have somebody that walks like obstructive HCM, severe obstructive HCM and they say they are asymptomatic. For me, that's a starting point for negotiation. I'm definitely going to make them prove it to me by way of provocation, IE most commonly stress, echo and talk to the family members. Yeah, I am asymptomatic because I stopped climbing to the top floor of my house. You know, I now have somebody else doing the laundry because I cannot carry the laundry basket and hence I'm asymptomatic. I don't think that's really asymptomatic.

Michelle M. Kittleson, MD, PhD: I agree with you 110%, and that's why I think AI will never take our jobs away from us. And it comes down to the beauty of a careful history and ancillary testing like an objective measure like a stress test to define their exercise capacity 100% degree.

Anjali Owens, MD: The longitudinal nature of the follow up and repeating the stress echo or the VO2 you know after years to see if there has been a decline in function and the last point to highlight which you mentioned Milan is the critical importance of getting family member history or caregivers.

Transcript is AI-generated and edited for clarity and readability.