A 42-year-old man presents with exertional syncope and a harsh crescendo-decrescendo systolic murmur at the left sternal border that increases with Valsalva manoeuvre and decreases with squatting. Echocardiography shows asymmetric septal hypertrophy 22 mm and LVOTO gradient of 70 mmHg at rest. What is the most appropriate first-line pharmacological treatment?

• A Nitrates for symptom relief
• B Beta-blocker (propranolol or metoprolol) ✓
• C Digoxin for heart rate control
• D ACE inhibitor to reduce afterload

Explanation

Hypertrophic obstructive cardiomyopathy (HOCM) with LVOTO is first managed with negative inotropes/chronotropes — beta-blockers are first-line, reducing LVOTO gradient, improving diastolic filling time, and alleviating symptoms including syncope and exertional dyspnoea. Nitrates and vasodilators (ACE inhibitors) are contraindicated as they reduce preload/afterload, worsening LVOTO. Digoxin increases contractility and worsens outflow obstruction. Mavacamten (myosin inhibitor) is a newer approved option for symptomatic obstructive HCM.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.