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(Circulation. 1997;95:1981-1982.)
© 1997 American Heart Association, Inc.

Articles

Induced Septal Infarction

A New Therapeutic Strategy for Hypertrophic Obstructive Cardiomyopathy

Eugene Braunwald, MD

From the Department of Medicine, Brigham and Women's Hospital, Boston, Mass.

Correspondence to Eugene Braunwald, MD, Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.

Key Words: Editorials • cardiomyopathy • infarction • hypertrophy

	Introduction

 
It is well known that patients with hypertrophic obstructive cardiomyopathy (HOCM) respond in a paradoxical manner to a variety of stimuli. Early in the development of our understanding of this condition, it was observed that drugs such as digitalis, sympathomimetic amines, and nitroglycerin that benefit patients with many other forms of heart disease intensify obstruction to left ventricular outflow and exert an adverse clinical effect on patients with HOCM.¹ In contrast, pharmacological agents such as disopyramide and verapamil, which depress myocardial contractility and sometimes provoke heart failure in patients with dilated hearts, are often beneficial in HOCM patients. Similarly, pregnancy and the associated hypervolemia, which so frequently aggravate other forms of heart disease, often reduce symptoms in patients with HOCM. In this issue of Circulation, another seemingly paradoxical therapy is reported: the induction of a localized myocardial infarction, which appears to be beneficial in patients with this condition.²

The basis for these paradoxical responses is clear. Obstruction to left ventricular outflow in HOCM is caused by the systolic approximation of the anterior leaflet of the mitral valve and the hypertrophied, superior portion of the interventricular septum. The obstruction is dynamic, with increases in contractility aggravating the obstruction and depressions in contractility exerting the opposite effect.

Four distinct strategies for the management of HOCM, based on an appreciation of this pathophysiology, are currently used:

1. The first strategy, and one that is still widely employed, consists of surgical incision into and excision of a portion of the asymmetrically hypertrophied subaortic . . . [Full Text of this Article]

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