Treatment options for hypertrophic obstructive cardiomyopathy in the era of myosin inhibitors

Hypertrophic obstructive cardiomyopathy (HOCM) is characterised by left ventricular outflow tract obstruction (LVOTO) caused by septal hypertrophy and its interaction with the mitral valve and systolic anterior motion. Symptoms include dyspnoea, angina, palpitations, syncope, fatigue and sudden cardiac death. This review provides a comprehensive overview and breakdown of current available treatment options, including traditional medical therapies and surgical septal reduction therapies in the era of new emerging pharmacologic options, including myosin inhibitors. Traditional pharmacotherapy includes non-vasodilating beta blockers, calcium-channel blockers and disopyramide. For persistent symptoms, surgical myectomy and alcohol septal ablation remain important septal reduction therapies, with treatment choice depending on anatomy, procedural risk and site-specific expertise. Myosin inhibitors, including mavacamten and aficamten, offer a targeted approach to addressing the hypercontractility characteristic of hypertrophic obstructive cardiomyopathy, by directly modulating sarcomeric function. These agents may move earlier in the treatment pathway for selected patients with HOCM, although longer-term data, access, monitoring burden and cost-effectiveness remain important considerations.