Hypertrophic Cardiomyopathy (HCM) Treatment: Medication, Lifestyle, Surgery, and More
Hypertrophic cardiomyopathy (HCM) is a condition in which tissues in the heart become thickened, which can make it difficult for the organ to pump blood throughout the body.
HCM does not always have strong symptoms, but even mild cases require regular treatment to reduce the long-term risk of cardiovascular disease. The condition can worsen over time, so it’s important to keep follow-up appointments to monitor any changes and keep up with appropriate treatments.
“Treatment of HCM requires ongoing care with a cardiologist,” says Jeffrey Geske, MD, a cardiologist at Mayo Clinic in Minnesota, who specializes in HCM. “But with modern care, most patients with HCM have a normal lifespan.”
If you require medical interventions to manage your HCM, your physician will likely start with medication. Your physician can choose from many types of drugs to help support your cardiovascular health.
Beta-Blockers
Beta-blockers are pills that decrease blood pressure and heart rate, putting less tension on the heart wall. Medications in this class include:
atenolol
bisoprolol
carvedilol phosphate
metoprolol succinate
propranolol
Common side effects include fatigue, upset stomach, headaches, dizziness, constipation or diarrhea, and lightheadedness. Potential side effects that warrant medical care include chest pain, breathing problems, slow or irregular heartbeats, and swelling in the hands, feet, ankles, or legs.
Calcium Channel Blockers
Similar to beta-blockers, calcium channel blockers, also known as calcium channel antagonists, reduce strain on the heart by lowering heart rate. Your doctor may try a calcium channel blocker if a beta-blocker was ineffective. For HCM, doctors prescribe nondihydropyridine calcium channel blockers, which do not significantly dilate the blood vessels, including:
verapamil
diltiazem
Some people experience side effects when taking nondihydropyridine calcium channel blockers, including constipation, low blood pressure, elevated liver enzymes, dizziness, and fatigue. In more severe cases, people may have issues with arrhythmias (irregular heartbeats) or heart rate.
Anti-Arrhythmics
Anti-arrhythmics are medications that treat arrhythmias, which can develop as a result of HCM. The anti-arrhythmic most commonly used in HCM is a medication called disopyramide.
Anti-arrhythmics can cause a variety of side effects, including dizziness, palpitations, gastrointestinal distress, and chest pain.
Blood Thinners
Your doctor may put you on a blood thinner if you have an atrial fibrillation, the most common arrhythmia in people with HCM. Blood thinners prevent blood clots, which can cause stroke. Common types of blood thinners include:
warfarin (Jantoven)
dabigatran (Pradaxa)
rivaroxaban (Xarelto)
apixaban (Eliquis)
Blood thinners can cause excessive bleeding — including nosebleeds, bruising, and heavy menstrual periods — in addition to gastrointestinal problems, allergic reactions, headaches, and dizziness.
Cardiac Myosin Inhibitors
There is only one medication specifically approved to treat HCM: mavacamten (Camzyos). This drug, a cardiac myosin inhibitor, treats people with obstructive HCM who have advanced symptoms. It acts directly on the heart muscle, reducing the force of the heart’s contractions, which reduces obstruction and allows blood to flow out of the heart more freely.
Mavacamten can reduce the symptoms of HCM and increase exercise capacity. However, because the drug carries a risk of heart failure, it is only available through an FDA program with special monitoring requirements. Other side effects may include dizziness or fainting.
Surgery is typically only necessary when thickening of tissue in the heart is severe or if a person has significant symptoms that don’t respond well to medication.
If surgery is necessary, having an operation “can result in dramatic improvement in how patients feel,” Dr. Geske says.
Septal Myectomy
A septal myectomy is considered the gold standard surgery for HCM. It is an open-heart surgery that removes parts of thickened heart tissue between the walls of the heart chambers. Though open-heart surgery is an invasive procedure that usually requires days of recovery in the hospital, it is considered low-risk, though there is always a possibility of complications from surgery. A septal myectomy improves HCM symptoms quickly and rarely causes long-term health problems.
Septal Ablation
A septal ablation, also called a septal myocardial ablation or alcohol septal ablation (ASA), is a minimally invasive procedure that uses alcohol to shrink thickened heart tissue.
“Alcohol ablation has the advantage of being less invasive than myectomy,” Geske says. During the operation, the surgeon guides a catheter into an artery that supplies blood to the thickened part of the heart and sprays alcohol on thickened tissue.
Though septal ablation is significantly less invasive than septal myectomy, it is associated with less dramatic symptom relief and a higher risk of complications, such as accidental damage to the heart.
Heart Transplant
It’s rare for HCM to cause enough damage to require a heart transplant, but the procedure may be necessary in people with HCM and additional heart conditions, such as advanced heart failure. In these cases, people typically have a good 10-year survival rate post transplant.
In very rare cases, patients with HCM can develop a weakened heart, sometimes called “burn out,” Geske says. These people may need implanted devices or a heart transplant.
Some people with HCM, particularly those who develop arrhythmias, may need an implanted device to keep their heart running well and to avoid cardiac arrest (when the heart stops beating).
Implantable Cardioverter-Defibrillator (ICD)
The implantable cardioverter-defibrillator (ICD) is the most frequently used implantable device in the treatment of HCM. It is used especially in patients with HCM who have arrhythmias that put them at risk for cardiac arrest, or who have a family history of cardiac arrest from HCM.
An ICD is a small electronic device that is implanted under the skin; it’s connected to the heart by small wires. This device detects potentially fatal arrhythmias. If someone has a disrupted heart rhythm, the device sends an electrical shock to the heart, causing it to beat regularly again. Some ICDs also work as pacemakers, keeping the heart beating regularly.
Cardiac Resynchronization Therapy (CRT) Device
A cardiac resynchronization therapy (CRT) device is a pacemaker that keeps the left and right ventricles in sync, improving the amount of blood the heart can pump. Only a minority of people with HCM develop complications that would qualify them for a CRT device, which is generally used to treat severe heart failure.
Ventricular Assist Device (VAD)
Also called a left ventricular assist device (LVAD), a VAD implant is only used in patients with severe heart failure. The implant is a pacemaker that targets the left ventricle, which is most commonly the part of the heart impacted by HCM.
“In HCM, the heart is too muscular,” Geske says. “Therefore, most patients with HCM have an extra strong heart, not a weak one. CRT and VADs are therapies used in most cases for weakened hearts, thus, they are rarely used in HCM.”
People with HCM may be at an enhanced risk of cardiovascular disease, and therefore should try to follow expert recommendations for a heart-healthy lifestyle, such as adopting a healthy diet and exercise habits.
Get Regular Exercise, but Avoid Short Bursts
Some nervousness around exercise is natural in people with HCM, especially when physical activity causes symptoms like chest pain or shortness of breath. And in rare cases, HCM can cause death by sudden cardiac arrest. This tragic outcome most famously occurs in young athletes, sometimes while they’re exercising.
“The first thing I tell patients is don’t be scared of exercising,” says Ningxin Wan, MD, a cardiologist at NewYork-Presbyterian Queens in Flushing, New York, and assistant professor at Weill Cornell Medicine. But your cardiologist may tell you to avoid types of exercise that could overstress your heart.
Aim for sustained, regular, moderate endurance exercises like cycling, elliptical, walking, and jogging. Anything that requires sudden bursts of straining isn’t good for people with HCM, Dr. Wan says.
“What we don’t recommend is exercise that requires intense bursts like heavy weight lifting, contact sports, or anything that needs the patient to suddenly move or strain themselves. That gives the heart a sudden exercise rather than sustained, which can aggravate obstruction,” she says.
You should also not exercise on a full stomach or right after eating, since a full stomach can put pressure on the heart and make symptoms worse during exercise.
Stay Hydrated
Dehydration can worsen HCM symptoms.
“When you are dehydrated it’s easier for the sick heart muscle to get in the way and obstruct blood flow,” Wan says.
Though HCM doesn’t necessarily increase the risk of heart failure, studies have shown that regularly not drinking enough fluids can cause scarring in the heart tissue that increases that risk. It is even more important for people with underlying heart conditions like HCM to be sure to stay hydrated.
Avoid Extreme Heat
Subjecting your body to extreme heat like that of a sauna, steamroom, or hot tub, can make HCM symptoms worse, Wan says, so it’s best to avoid these situations. Immersing your body in moist heat can cause your blood pressure to drop, which increases the demands on your heart, a process that is sometimes exacerbated by common heart disease medications. The potential consequences include dizziness, irregular heartbeat, and even heart attack.
Lose Weight, if Necessary
Obesity puts extra strain on the heart in many different ways, and is strongly associated with cardiovascular risks. If you are overweight or have obesity, your cardiologist may work with a weight loss expert to determine what avenue is best for you. Wan says she sometimes prescribes GLP-1 medications to her patients with both HCM and obesity.
HCM can seem mild or benign, but it is still important to see a cardiologist regularly, as treatment can help reduce the long-term risk of cardiovascular disease.
Some people with HCM will need surgery or an implanted device, but these treatments are considered safe and effective.
HCM does not need to strongly affect your quality of life, but your doctor may ask you to make some small adjustments, such as avoiding high-intensity exercise.
