Atrial electrophysiology in hypertrophic cardiomyopathy: current insights and knowledge gaps

Hypertrophic cardiomyopathy is the most common inherited cardiac condition, associated with increased risks of heart failure, arrhythmias, and sudden cardiac death. Once considered a disease of the ventricular myocardium, growing evidence points towards atrial involvement, with structural and electrical atrial remodelling driven by a complex interplay of genetic, electrophysiological and hemodynamic factors. Despite advances in the understanding of this atrial substrate, management of atrial arrhythmias in hypertrophic cardiomyopathy remains challenging. Pharmacological therapies are limited by safety concerns, and catheter ablation shows lower efficacy in patients with hypertrophic cardiomyopathy compared to patients with structurally normal hearts. This review synthesizes current knowledge of disease related changes underlying atrial arrhythmias in hypertrophic cardiomyopathy and outlines diagnostic and therapeutic strategies. Particular emphasis is given to interventional treatment approaches, including emerging technologies and their evolving role in patients with hypertrophic cardiomyopathy.