Current Treatment Options in Cardiovascular Medicine (2012) 14:665–678 DOI 10.1007/s11936-012-0206-5 Valvular Heart Disease (AS Desai and PT O'Gara, Section Editors) Medical, Surgical and Interventional Management of Hypertrophic Cardiomyopathy With Obstruction Sammy Elmariah, MD, MPH Michael A. Fifer, MD * Address *Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, GRB-800, Boston, MA 02114, USA Email: mfifer@partners.org Published online: 6 September 2012 * Springer Science+Business Media, LLC 2012 Keywords Alcohol septal ablation I Atrial fibrillation I Beta blocker I Calcium channel blocker I Disopyramide I Hypertrophic obstructive cardiomyopathy I Pacemaker I Septal myectomy I Septal reduction therapy I Sudden cardiac death Opinion statement Patients with hypertrophic cardiomyopathy (HCM) are classified as having hypertro- phic obstructive cardiomyopathy (HOCM) if a left ventricular outflow tract (LVOT) gradient is present at rest or during provocation, as with Valsalva maneuver or ex- ercise. Management of HCM in general and HOCM in particular encompasses (1) ac- tivity restriction with avoidance of volume depletion, (2) prevention of sudden cardiac death, (3) control of symptoms, and (4) screening of relatives. Those patients at high risk of sudden cardiac death (SCD) should be offered an implant- able cardioverter-defibrillator (ICD). Pharmacologic treatment of symptoms in patients with HOCM consists of negative inotropic drugs, namely beta blockers, and disopyramide; a nondihydropyridine calcium channel blocker (CCB), usually ve- rapamil, may be used in patients with noncardiac side-effects of beta blockers. Patients who have a dual-chamber pacemaker (PM) or ICD should undergo a trial of pacing with short atrioventricular (AV) delay. For patients with intolerable symp- toms despite optimal conservative therapy, septal reduction therapy (SRT) should be considered and should be performed by experienced operators in institutions with multidisciplinary HCM programs. Younger patients with extreme hypertrophy are usually offered septal myectomy, while older patients, and those with important comorbidities are usually directed to alcohol septal ablation (ASA). For patients for whom either therapy is appropriate, there should be a balanced discussion with the patients of the benefits and risks of the 2 procedures.