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Invited Commentary
February 6, 2019

Nonobstructive Hypertrophic Cardiomyopathy—The High-Hanging Fruit

Author Affiliations
  • 1Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor
JAMA Cardiol. 2019;4(3):235-236. doi:10.1001/jamacardio.2018.4953

Relief of symptomatic left ventricular outflow tract obstruction has been the focus of treatment interventions for patients with hypertrophic cardiomyopathy (HCM) for decades. Negative inotropic drugs and septal reduction therapy for medically refractory cases are highly effective strategies for alleviating outflow tract obstruction and improving symptoms.1 Symptomatic, nonobstructive HCM has proven a bigger challenge. To date, therapeutic options are limited to a trial-and-error approach with a combination of β-blockers, calcium channel blockers, and diuretics.1 Symptomatic, nonobstructive disease affects a large proportion of the population with HCM. About 30% to 40% of HCM cohorts described in published data in whom exercise-provoked gradients were assessed have nonobstructive disease, and of those, approximately 35% to 40% are symptomatic (defined as having a New York Heart Association functional class of II or greater).2,3 Perhaps counter to common perceptions that nonobstructive disease is more benign than obstructive disease, a recent meta-analysis of 20 studies of 7731 patients with HfCM showed no difference in the risk of sudden or heart failure–associated deaths in patients with nonobstructive compared with obstructive disease.4 Developing effective and targeted therapies for symptomatic nonobstructive HCM is therefore imperative and represents one of the largest unmet needs in the field.

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