In hypertrophic obstructive cardiomyopathy, what is the first-line treatment for relief of symptoms?

• A. Beta blocker
• B. Calcium channel blocker
• C. ACE inhibitor
• D. Nitrates

Answer: (A)

In hypertrophic obstructive cardiomyopathy, the goal is to reduce the dynamic obstruction of the left ventricular outflow tract. Slowing the heart rate and decreasing contractility with a beta-blocker lowers the LVOT gradient, improves diastolic filling, and diminishes the systolic anterior motion of the mitral valve. This directly improves symptoms such as chest pain and shortness of breath. Calcium channel blockers can be used if beta-blockers aren’t tolerated, but they’re not the preferred first choice. Vasodilators like nitrates and agents that reduce afterload or preload (such as ACE inhibitors) can worsen the obstruction by decreasing preload or afterload, so they’re not first-line.