Choosing Between Septal Reduction and Myosin Inhibitors in oHCM Patients

Despite rapid therapeutic advances, oHCM remains a chronic, progressive, and heterogeneous disease.

Mariko Harper, MD, notes that while cardiac myosin inhibitors have “obliterated” obstruction for many patients and substantially improved exercise capacity and daily functioning, they are currently positioned as long-term therapies rather than proven disease-modifying agents. Moreover, many patients with nonobstructive HCM, or those who may transition from nonobstructive to obstructive disease over time, lack robust data to guide preventive or early use of cardiac myosin inhibitors, underscoring the need for continued surveillance and research across the HCM spectrum.

Matthew Martinez, MD, stresses that no single strategy can address all clinical scenarios. Some patients favor the durability and procedural finality of septal reduction therapy (surgical myectomy or alcohol septal ablation), particularly when they seek to minimize long-term medication exposure. The discussion becomes especially complex for individuals of childbearing potential and adolescents or young adults who might otherwise face many decades of continuous medical therapy. For these groups, Martinez and Harper contemplate whether a staged strategy—achieving stability through growth and then intervening with septal reduction at an optimal time—may be more appropriate than lifelong pharmacologic management alone.

Within this framework, the experts describe an “and” rather than “or” paradigm, with cardiac myosin inhibitors and septal reduction procedures functioning as complementary rather than mutually exclusive options. In this segment, Martinez and Harper demonstrate how life stage, reproductive planning, anticipated adherence, and long-term care infrastructure influence the selection and sequencing of interventions. The conversation illustrates the need for individualized, longitudinal planning and shared decision-making when balancing medical therapy and procedural options in complex oHCM populations.