How should I approach the management of a patient with hypertrophic cardiomyopathy who presents with exertional dyspnoea?

Approach to managing a patient with hypertrophic cardiomyopathy (HCM) presenting with exertional dyspnoea involves a comprehensive assessment and tailored treatment to improve symptoms and reduce complications.

Initially, confirm the diagnosis and assess the severity of left ventricular outflow tract (LVOT) obstruction and diastolic dysfunction, as these are common contributors to exertional dyspnoea in HCM ¹. Symptom management begins with lifestyle advice, including avoidance of strenuous exertion and dehydration, which can exacerbate obstruction ¹. Pharmacological treatment primarily involves beta-blockers or non-dihydropyridine calcium channel blockers to reduce heart rate, improve diastolic filling, and decrease LVOT gradient, thereby alleviating dyspnoea ¹ (Naghi and Siegel, 2025).

If symptoms persist despite optimal medical therapy and significant LVOT obstruction is present, consider invasive options such as septal reduction therapy (surgical myectomy or alcohol septal ablation) to relieve obstruction and improve exercise capacity ¹ (Schaff and Wei, 2024). Additionally, managing comorbidities like atrial fibrillation or hypertension is essential to optimize cardiac function ¹ (Maron et al., 2018).

Regular follow-up with echocardiographic monitoring and symptom reassessment is critical to guide ongoing management and detect progression ¹. In refractory cases or those with advanced heart failure symptoms, evaluation for advanced therapies including implantable cardioverter-defibrillators (ICDs) for sudden cardiac death prevention and heart transplantation referral may be warranted (Maron et al., 2018).

In summary, the management of exertional dyspnoea in HCM is a stepwise approach starting with medical therapy to reduce LVOT obstruction and improve diastolic function, lifestyle modification, and progressing to septal reduction procedures if needed, all while monitoring for complications and comorbidities ¹ (Naghi and Siegel, 2025; Maron et al., 2018; Schaff and Wei, 2024).