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Matthew Budoff, MD, reviews key points from the 2024 HCM guidelines, including recreational exercise, AF, and ICD risks, and discusses the possible impacts.
Recreational exercise, atrial fibrillation (AF), and implantable cardioverter-defibrillators (ICD) were among key topics in the 2024 hypertrophic cardiomyopathy (HCM) management guidelines issued by the American Heart Association and the American College of Cardiology Joint Committee on Clinical Practice Guidelines.
To update the 2020 recommendations, the writing committee reviewed human studies, reviews, and other evidence. The new guidelines, published in the Journal of the American College of Cardiology and Circulation, updated or added information regarding pharmacological management, stress tests, competitive sports, and more.
Physician’s Weekly (PW) spoke with cardiologist Matthew Budoff, MD, about how the changes might impact clinical practice.
PW: How has the approach to AF screening changed from 2020 to the 2024 guidelines?
Dr. Budoff: There has been increased emphasis on continued ambulatory monitoring to better capture AF. The focus is on making sure we don’t miss episodes of AF because it’s so poorly tolerated in patients with HCM and is associated with increased risk of stroke.
Nowadays, we have much better tools for extended ambulatory monitoring. Many different devices can be used, from watches to implantables and everything in between. We are very capable of capturing incidental or paroxysmal AF.
It is important to remember that patients with HCM need to receive anticoagulation regardless of CHA2DS2-VASc score because of their risk for stroke, but also because the stiff ventricle doesn’t tolerate AF well. This might exacerbate symptoms and even lead to episodes of heart failure in these patients.
How have the guidelines for ICD placement evolved, and how will this impact clinical practice?
The guidelines have reemphasized that patients with the HCM genotype but not the phenotype (they don’t have the thickened ventricle or heart failure) should not get an ICD. We don’t treat the genetics alone. This new guideline emphasizes that it is a Class 3 recommendation in several places.
How do you discuss ICD placement with patients who are at risk for sudden cardiac death?
Patients need to understand that it’s possible their ICD could be discharged inappropriately if they get high heart rates or have other issues. It’s an overall risk-benefit discussion for each patient.
What should clinicians consider during annual evaluations with patients participating in high-intensity, recreational or competitive sports?
The guidelines no longer universally restrict vigorous physical activity. Although the previous iteration of the guidelines contained somewhat restrictive language, this has now been removed.
It must be emphasized that patients with HCM still need an annual, comprehensive review of their cardiovascular risk. That includes an echocardiogram and a treadmill test. If they do well with those tests, and they’re doing well clinically, there is no longer a restriction from vigorous physical activity or competitive sports.
How has your approach to annual comprehensive evaluations changed over time?
I’ve been better at making sure patients get their annual treadmill test. We’ve always done echocardiography routinely, done a good physical exam, and talked to patients about symptomatology. But now, I also make sure we’re conducting exercise treadmill tests annually to examine patients’ physical capacity, symptoms, and heart rate when they are under stress.
Is there anything else you would like to add?
These are modest changes, but they are an important update for all of us caring for patients with HCM.
