Beta-Blocker Management in Obstructive Hypertrophic Cardiomyopathy Treated with Mavacamten: A Practical Approach.

Abstract

Beta-blockers are the cornerstone of first-line therapy for symptomatic obstructive hypertrophic cardiomyopathy (oHCM), whereas mavacamten has recently emerged as an effective disease-specific treatment targeting the underlying hypercontractile state. However, the optimal management of concomitant beta-blocker therapy following mavacamten initiation remains uncertain. Available evidence indicates that beta-blockers do not diminish the favorable effects of mavacamten on left ventricular outflow tract obstruction or symptom relief but may attenuate improvements in exercise capacity due to chronotropic limitation. This work reviews the current evidence regarding beta-blocker use during mavacamten therapy and discusses the pathophysiological mechanisms underlying this interaction. Based on the available data, we propose a practical, physiology-guided approach in which continuation of beta-blockers is reserved for patients with specific clinical indications, including atrial fibrillation requiring rate control, myocardial ischemia, or increased ventricular arrhythmic risk, while cautious dose reduction or withdrawal may be considered in selected patients with persistent chronotropic incompetence after effective relief of obstruction. Prospective studies are needed to define the optimal strategy for integrating beta-blockers with cardiac myosin inhibition in oHCM.