View source for Cardiomyopathy 2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy

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{{Cardiomyopathy}}
{{CMG}}; {{AE}} {{EdzelCo}}

==2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy <ref name="pmid33215938">{{cite journal| author=Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P | display-authors=etal| title=2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2020 | volume= 142 | issue= 25 | pages= e533-e557 | pmid=33215938 | doi=10.1161/CIR.0000000000000938 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33215938  }} </ref> ==




====<u> Recommendation for Shared Decision-Making </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. For [[patients]] with [[HCM]] or at risk for [[HCM]], shared decision-making is recommended in developing a plan of [[care]] (including but not limited to decisions regarding [[genetic]] evaluation, activity, [[lifestyle]], and [[therapy]] choices) that includes a full disclosure of the risks, benefits, and anticipated outcomes of all options, as well the opportunity for the [[patient]] to express their goals and concerns. 
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendation for Multidisciplinary HCM Centers </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]] in whom [[septal reduction therapy]] ([[SRT]]) is indicated, the procedure should be performed at experienced centers (comprehensive or primary HCM centers) with demonstrated excellence in [[clinical]] outcomes for these procedures. 
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]], consultation with or referral to a comprehensive or primary HCM center is reasonable to aid in complex [[disease]]-related management decisions.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendation for Diagnosis, Initial Evaluation, and Follow-up </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with suspected [[HCM]], comprehensive [[physical examination]] and complete [[medical]] and 3-[[generation]] [[family history]] is recommended as part of the initial [[diagnostic]] assessment. 
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendation for Echocardiography </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with suspected [[HCM]], a [[trans-thoracic echocardiogram]] ([[TTE]]) is recommended in the initial evaluations. 
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| rowspan="2" bgcolor="LightGray" |2. In [[patients]] with [[HCM]] with no change in [[clinical status]] or events, repeat [[TTE]] is recommended every 1 to 2 years to assess the degree of [[myocardial]] [[hypertrophy]], dynamic [[left ventricular outflow tract obstruction]] ([[LVOTO]]), [[mitral regurgitation]], and [[myocardial function]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR children
|-
| bgcolor="PaleTurquoise" style="text-align:center;" ; |C-LD adult
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |3. For [[patients]] with [[HCM]] who experience a change in [[clinical status]] or a new [[clinical event]], repeat [[TTE]] is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |4. For [[patients]] with [[HCM]] and resting [[left ventricular outflow tract]] gradient <50 mm Hg, a [[TTE]] with provocative maneuvers is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |6. For [[symptomatic]] [[patients]] with [[HCM]] who do not have a resting or provocable outflow tract gradient ≥50 mm Hg on [[TTE]], exercise [[TTE]] is recommended for the detection and quantification of dynamic [[LVOTO]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |7. For [[patients]] with [[HCM]] undergoing [[surgical]] [[septal myectomy]], [[intraoperative]] [[transesophageal echocardiogram]] ([[TEE]]) is recommended to assess [[mitral valve anatomy]] and [[function]] and adequacy of [[septal myectomy]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |8. For [[patients]] with [[HCM]] undergoing [[alcohol septal ablation]], [[TTE]] or [[intraoperative]] [[TEE]] with [[intracoronary]] [[ultrasound]]-enhancing [[contrast]] injection of the candidate’s [[septal perforator]](s) is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |9. [[Screening]]: In first-degree relatives of [[patients]] with [[HCM]], a [[TTE]] is recommended as part of initial [[family screening]] and periodic  [[follow-up]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |10. Screening: In individuals who are [[genotype]]-positive or [[phenotype]]-negative, serial [[echocardiography]] is recommended at periodic intervals depending on age (1 to 2 years in [[children]] and [[adolescents]], 3 to 5 years in adults) and change in [[clinical status]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |11. For [[patients]] with [[HCM]], [[TEE]] can be useful if [[TTE]] is inconclusive in [[clinical]] decision-making regarding [[medical]] [[therapy]], and in situations such as planning for [[myectomy]], exclusion of [[subaortic]] membrane or [[mitral regurgitation]] secondary to structural abnormalities of the [[mitral valve apparatus]], or in the assessment of the feasibility of [[alcohol septal ablation]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |12. For [[patients]] with [[HCM]] in whom the [[diagnoses]] of [[apical HCM]], [[apical aneurysm]], or atypical patterns of [[hypertrophy]] is inconclusive on [[TTE]], the use of an [[intravenous]] [[ultrasound]]-enhancing agent is reasonable particularly if other imaging modalities such as [[cardiovascular magnetic resonance]] ([[CMR]]) are not readily available or contraindicated.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
|bgcolor="LightGray" |13. For [[asymptomatic]] [[patients]] with [[HCM]] who do not have a resting or provocable outflow tract gradient ≥50 mm Hg on standard [[TTE]], [[exercise TTE]] is reasonable for the detection and quantification of dynamic [[LVOTO]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendation for Cardiovascular Magnetic Resonance Imaging </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. For [[patients]] suspected to have [[HCM]] in whom [[echocardiography]] is inconclusive, [[CMR]] [[imaging]] is indicated for [[diagnostic]] clarification.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. For [[patients]] with [[left ventricular hypertrophy]] in whom there is a suspicion of alternative [[diagnoses]] including infiltrative or storage [[disease]] as well as athlete’s [[heart]], [[CMR]] [[imaging]] is useful.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. For [[patients]] with [[HCM]] who are not otherwise identified as high risk for [[sudden cardiac death]] ([[SCD]]), or in whom a decision to proceed with [[implantable cardioverter defibrillator]] ([[ICD]]) remains uncertain after [[clinical assessment]] that includes personal/[[family history]], [[echocardiography]], and ambulatory [[electrocardiographic]] monitoring, [[CMR]] imaging is beneficial to assess for maximum [[left ventricular]] ([[LV]]) wall thickness, [[ejection fraction]] ([[EF]]), [[LV apical aneurysm]], and extent of [[myocardial fibrosis]] with late [[gadolinium]] enhancement.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. For [[patients]] with [[obstructive HCM]] in whom the [[anatomic]] mechanism of [[obstruction]] is inconclusive on [[echocardiography]], [[CMR]] [[imaging]] is indicated to inform the selection and planning of [[SRT]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. For [[patients]] with [[HCM]], repeat [[contrast]]-enhanced [[CMR]] [[imaging]] on a periodic basis (every 3 to 5 years) for the purpose of [[SCD]] [[risk stratification]] may be considered to evaluate changes in late [[gadolinium]] enhancement and other morphologic changes, including [[EF]], development of [[apical aneurysm]], or [[LV]] wall thickness.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|}

====<u> Recommendation for Heart Rhythm Assessment </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]], a [[12-lead ECG]] is recommended in the initial evaluation and as part of periodic [[follow-up]] (every 1 to 2 years)
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]], 24- to 48-hour ambulatory [[electrocardiographic]] monitoring is recommended in the initial evaluation and as part of periodic follow-up (every 1 to 2 years) to identify [[patients]] who are at risk for [[SCD]] and guide management of [[arrhythmias]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[HCM]] who develop [[palpitations]] or [[lightheadedness]], extended (>24 hours) [[electrocardiographic]] monitoring or event recording is recommended, which should not be considered [[diagnostic]] unless [[patients]] have had [[symptoms]] while being monitored.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In first-degree relatives of [[patients]] with [[HCM]], a [[12-lead ECG]] is recommended as a component of the screening algorithm.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. In [[patients]] with [[HCM]] who have additional [[risk factors]] for [[atrial fibrillation]] ([[AF]]), such as [[left atrial dilatation]], advanced [[age]], and [[New York Heart Association]] ([[NYHA]]) class III to class IV [[heart failure]] ([[HF]]), and who are eligible for [[anticoagulation]], extended ambulatory monitoring is reasonable to screen for [[AF]] as part of initial evaluation and periodic [[follow-up]] (every 1 to 2 years)
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. In [[adult]] [[patients]] with [[HCM]] without [[risk factors]] for [[AF]] and who are eligible for [[anticoagulation]], extended ambulatory monitoring may be considered to assess for [[asymptomatic paroxysmal AF]] as part of initial evaluation and periodic follow-up (every 1 to 2 years).
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendation for Angiography and Invasive Hemodynamic Assessment </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. For [[patients]] with [[HCM]] who are candidates for [[SRT]] and for whom there is uncertainty regarding the presence or severity of [[LVOTO]] on [[noninvasive imaging studies]], invasive [[hemodynamic assessment]] with [[cardiac catheterization]] is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] with [[symptoms]] or evidence of [[myocardial ischemia]], [[coronary angiography]] ([[CT]] or invasive) is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[HCM]] who are at risk of [[coronary]] [[atherosclerosis]], [[coronary angiography]] ([[CT]] or invasive) is recommended before [[surgical]] [[myectomy]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendation for Exercise Stress Testing </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. For [[symptomatic]] [[patients]] with [[HCM]] who do not have [[resting]] or provocable [[outflow tract]] gradient ≥50 mm Hg on [[TTE]], [[exercise TTE]] is recommended for the detection and quantification of dynamic [[LVOTO]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] with [[symptoms]] or evidence of [[myocardial ischemia]], [[coronary angiography]] ([[CT]] or invasive) is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[HCM]], [[exercise stress testing]] is reasonable to determine [[functional capacity]] and to provide [[prognostic]] information as part of initial evaluation.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. For [[asymptomatic]] [[patients]] with [[HCM]] who do not have a [[resting]] or provocable [[outflow tract]] gradient ≥50 mm Hg on [[standard TTE]], [[exercise TTE]] is reasonable for the detection and quantification of dynamic [[LVOTO]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. In [[patients]] with [[obstructive HCM]], who are being considered for [[SRT]], and in whom [[functional]] capacity or [[symptom]] status is uncertain, [[exercise stress testing]] may be reasonable.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6. In [[patients]] with [[HCM]] in whom functional capacity or [[symptom]] status is uncertain, [[exercise stress testing]] may be considered every 2 to 3 years.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|}

====<u> Recommendation for Genetics and Family Testing </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]], evaluation of [[familial inheritance]], including a 3-[[generation]] [[family history]], is recommended as part of the initial assessment.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]], [[genetic testing]] is beneficial to elucidate the [[genetic]] basis to facilitate the identification of [[family]] members at risk for developing [[HCM]] (cascade testing).
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with an atypical [[clinical presentation]] of [[HCM]] or when another [[genetic]] condition is suspected to be the cause, a work-up including [[genetic testing]] for [[HCM]] and other [[genetic]] causes of unexplained [[cardiac hypertrophy]] (“[[HCM]] [[phenocopies]]”) is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In [[patients]] with [[HCM]] who choose to undergo [[genetic testing]], pre- and posttest [[genetic counseling]] by an expert in the [[genetics]] of [[cardiovascular disease]] is recommended so that [[risks]], [[benefits]], results, and their [[clinical significance]] can be reviewed and discussed with the [[patient]] in a shared decision-making process.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. When performing [[genetic testing]] in an [[HCM]] [[proband]], the initial tier of [[genes]] tested should include [[genes]] with strong evidence to be [[disease]]-causing in [[HCM]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6. In first-degree relatives of [[patients]] with [[HCM]], both [[clinical]] screening ([[ECG]] and 2D [[echocardiogram]]) and cascade [[genetic testing]] (when a [[pathogenic]]/likely [[pathogenic]] variant has been identified in the [[proband]]) should be offered.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7. In [[families]] where a sudden unexplained [[death]] has occurred with a [[postmortem]] [[diagnosis]] of [[HCM]], [[postmortem]] [[genetic testing]] is beneficial to facilitate cascade [[genetic testing]] and [[clinical screening]] in first-degree relatives.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|8. In [[patients]] with [[HCM]] who have undergone [[genetic testing]], serial reevaluation of the [[variant]](s) identified is recommended to assess for [[variant]] reclassification, which may impact [[diagnosis]] and cascade [[genetic testing]] in [[family]] members.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|9. In affected [[families]] with [[HCM]], [[preconception]] and [[prenatal]] [[reproductive]] and [[genetic counseling]] should be offered.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|10. In [[patients]] with [[HCM]], the usefulness of [[genetic testing]] in the assessment of risk of [[SCD]] is uncertain.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|11. In [[patients]] with [[HCM]] who harbor a variant of uncertain significance, the usefulness of clinical [[genetic testing]] of [[phenotype]]-negative relatives for the purpose of variant reclassification is uncertain.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: No Benefit]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|12. For [[patients]] with [[HCM]] who have undergone [[genetic testing]] and were found to have no [[pathogenic]] [[variants]] (ie, harbor only benign/likely benign variants), cascade [[genetic testing]] of the [[family]] is not useful.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: No Benefit]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|13. Ongoing [[clinical screening]] is not indicated in [[genotype]]-negative relatives in families with [[genotype]]-positive [[HCM]], unless the [[disease]]-causing variant is downgraded to variant of uncertain significance, likely [[benign]], or [[benign]] variant during follow-up.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for Individuals Who Are Genotype-Positive, Phenotype-Negative </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In individuals who are [[genotype]]-positive, [[phenotype]]-negative for [[HCM]], serial [[clinical assessment]], [[electrocardiography]], and [[cardiac imaging]] are recommended at periodic intervals depending on [[age]] (every 1 to 2 years in [[children]] and [[adolescents]], and every 3 to 5 years in [[adults]]) and change in [[clinical status]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In individuals who are [[genotype]]-positive, [[phenotype]]-negative for [[HCM]], participation in competitive athletics of any intensity is reasonable.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: No Benefit]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In individuals who are genotype-positive, phenotype-negative for HCM, ICD is not recom-mended for primary prevention
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for SCD Risk Assessment </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]], a comprehensive, systematic noninvasive [[SCD risk assessment]] at initial evaluation and every 1 to 2 years thereafter is recommended and should include evaluation of these risk [[factors]]:
a.  [[Personal  history]]  of  [[cardiac  arrest]]  or  [[sustained ventricular arrhythmias]]
b.  [[Personal  history]]  of  [[syncope]]  suspected  by  [[clinical history]] to be [[arrhythmic]]
c.  [[Family  history]]  in  close  relative  of  premature  [[HCM]]- related  [[sudden  death]],  [[cardiac  arrest]], or [[sustained ventricular arrhythmias]]
d.  Maximal [[ LV  wall  thickness]],  [[EF]],  [[LV  apical  aneurysm]]
e.  Non-sustained  [[ventricular  tachycardia]]  episodes  on  continuous  ambulatory  [[electrocardiographic]] monitoring
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. For [[patients]] with [[HCM]] who are not otherwise identified as high risk for [[SCD]], or in whom a decision to proceed with [[ICD placement]] remains uncertain after [[clinical assessment]] that includes personal/]]family history]], [[echocardiography]], and ambulatory [[electrocardiographic monitoring]], [[CMR]] imaging is beneficial to assess for maximum [[LV wall thickness]], [[EF]], [[LV apical aneurysm]], and extent of [[myocardial fibrosis]] with late [[gadolinium enhancement]]
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. For [[patients]] who are ≥16 years of age with [[HCM]], it is reasonable to obtain [[echocardiography]]-derived left [[atrial]] diameter and maximal [[left ventricular outflow tract]] gradient to aid in calculating an estimated 5-year [[sudden death]] risk that may be useful during shared decision-making for [[ICD placement]]
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for ICD Placement in High-Risk Patients With HCM </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]], application of individual clinical judgment is recommended when assessing the [[prognostic]] strength of conventional risk marker(s) within the clinical profile of the individual patient, as well as a thorough and balanced discussion of the evidence, benefits, and estimated risks to engage the fully informed patient’s active participation in [[ICD]] decision-making.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. For [[patients]] with [[HCM]], and previous documented [[cardiac arrest]] or [[sustained ventricular tachycardia]], [[ICD placement]] is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3.  For adult [[patients]] with [[HCM]] with ≥1 major [[risk factors]] for [[SCD]], it is reasonable to offer an [[ICD]]. These major [[risk factors]] include:
a.  [[Sudden  death]]  judged  definitively  or  likely  attributable  to  [[HCM]]  in  ≥1  first-degree  or  close relatives who are ≤50 years of age;
b.  Massive  [[left  ventricular  hypertrophy]]  ≥30  mm in any [[left ventricular]] segment;
c. ≥1 Recent episodes of [[syncope]] suspected by  [[clinical  history]]  to  be  [[arrhythmic]]  (ie,  unlikely  to  be  of  [[neurocardiogenic]]  [[[vasovagal]]] [[etiology]], or related to [[LVOTO]]);
d. [[LV apical aneurysm]], independent of size;
e. [[LV]] [[systolic dysfunction]] ([[EF]] <50%)
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  For [[children]] with [[HCM]] who have ≥1 conventional [[risk factors]], including unexplained [[syncope]], massive [[left ventricular hypertrophy]], non-[[sustained ventricular tachycardia]], or [[family history]] of early [[HCM]]-related [[SCD]], [[ICD placement]] is reasonable after considering the relatively high complication rates of long-term [[ICD placement]] in younger [[patients]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  For [[patients]] ≥16 years of [[age]] with [[HCM]] and with ≥1 major [[SCD]] [[risk factors]], discussion of the estimated 5-year [[sudden death]] risk and [[mortality rates]] can be useful during the shared decision-making process for [[ICD placement]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Orange"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  In select [[adult]] [[patients]] with [[HCM]] and without major [[SCD]] [[risk factors]] after [[clinical assessment]], or in whom the decision to proceed with [[ICD placement]] remains otherwise uncertain, [[ICD]] may be considered in [[patients]] with extensive late [[gadolinium enhancement]] by [[contrast]]-enhanced [[CMR imaging]] or non-[[sustained ventricular tachycardia]] present on ambulatory monitoring.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7.  In select [[pediatric patients]] with [[HCM]] in whom [[risk stratification]] is otherwise less certain, it may be useful to consider additional factors such as extensive late [[gadolinium enhancement]] on [[contrast-enhanced]] [[CMR imaging]] and [[systolic dysfunction]] in [[risk stratification]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III:Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|8.  In [[patients]] with [[HCM]] without [[risk factors]], [[ICD placement]] should not be performed.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III:Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|9.  In [[patients]] with [[HCM]], [[ICD placement]] for the sole purpose of participation in competitive athletics should not be performed.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for Selection of ICD Device Type </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]] who are receiving an [[ICD]], either a single chamber [[trans-venous ICD]] or a [[subcutaneous ICD]] is recommended after a shared decision-making discussion that takes into consideration [[patient]] preferences, lifestyle, and expected potential need for pacing for [[bradycardia]] or [[ventricular tachycardia]] termination.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] who are receiving an [[ICD]], single-coil [[ICD]] leads are recommended in preference to dual coil [[leads]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3.  In [[patients]] with [[HCM]] who are receiving an [[ICD]], dual-chamber [[ICD]]s are reasonable for [[patients]] with a need for [[atrial]] or [[atrioventricular]] sequential pacing for [[bradycardia]]/[[conduction abnormalities]], or as an attempt to relieve [[symptoms]] of [[obstructive HCM]] (most commonly in [[patients]] >65 years of [[age]]).
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  In selected [[adult]] [[patients]] with non-[[obstructive HCM]] receiving an [[ICD]] who have [[NYHA class II]] to ambulatory [[class IV HF]], [[left bundle branch block]] ([[LBBB]]), and [[LV ejection fraction]] ([[LVEF]]) <50%, [[cardiac resynchronization therapy]] for [[symptom]] reduction is reasonable.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  In [[patients]] with [[HCM]] in whom a decision has been made for [[ICD implantation]] and who have [[paroxysmal atrial tachycardias]] or [[AF]], [[dual-chamber ICD]]s may be reasonable, but this decision must be balanced against higher complication rates of dual chamber [[devices]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendations for Pharmacologic Management of Patients With Obstructive HCM </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[obstructive HCM]] and [[symptoms]] attributable to [[LVOTO]], non-[[vasodilating]] [[beta blockers]], titrated to effectiveness or maximally tolerated [[doses]], are recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| rowspan="2" bgcolor="LightGray" |2. In [[patients]] with [[obstructive HCM]] and [[symptoms]] attributable to [[LVOTO]], for whom [[beta blockers]] are ineffective or not tolerated, substitution with [[non-dihydropyridine calcium channel blockers]] (eg, [[verapamil]], [[diltiazem]]) is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|[[Verapamil]]
B-NR
|-
|bgcolor= "PaleTurquoise"; style="text-align:center;|[[Diltiazem]]
C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3.  For [[patients]] with [[obstructive HCM]] who have persistent severe [[symptoms]] attributable to [[LVOTO]] despite [[beta blockers]] or [[non-dihydropyridine calcium channel blockers]], either adding [[disopyramide]] in combination with 1 of the other [[drugs]], or [[SRT]] performed at experienced centers,† is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Green"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  For [[patients]] with [[obstructive HCM]] and [[acute hypotension]] who do not respond to [[fluid]] administration, [[intravenous]] [[phenylephrine]] (or other [[vasoconstrictors]] without [[inotropic]] activity), alone or in combination with [[beta-block]]ing [[drugs]], is recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  For [[patients]] with [[obstructive HCM]] and persistent [[dyspnea]] with [[clinical]] evidence of [[volume overload]] and high left-sided [[filling pressures]] despite other [[HCM]] guideline-directed [[management]] and [[therapy]], cautious use of low-dose [[oral]] [[diuretics]] may be considered.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  For [[patients]] with [[obstructive HCM]], discontinuation of [[vasodilators]] (eg, [[angiotensin-converting enzyme inhibitors]], [[angiotensin receptor blockers]], [[dihydropyridine calcium channel blockers]]) or [[digoxin]] may be reasonable because these agents can worsen [[symptoms]] caused by [[dynamic outflow tract obstruction]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7.  For [[patients]] with [[obstructive HCM]] and severe [[dyspnea]] at [[rest]], [[hypotension]], very high [[resting gradients]] (eg, >100 [[mm Hg]]), as well as all [[children]] <6 weeks of [[age]], [[verapamil]] is potentially harmful.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendations for Invasive Treatment of Symptomatic Patients With Obstructive HCM </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[obstructive HCM]] who remain severely [[symptomatic]] despite guideline-directed [[management]] and [[therapy]], [[SRT]] in eligible [[patients]],performed at experienced centers,† is recommended for relieving [[LVOTO]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[symptomatic]] [[patients]] with [[obstructive HCM]] who have associated [[cardiac disease]] requiring [[surgical treatment]] (eg, associated anomalous [[papillary muscle]], markedly elongated [[anterior mitral leaflet]], intrinsic [[mitral valve disease]], multi-[[vessel]] [[coronary artery disease]], [[valvular]] [[aortic stenosis]]), [[surgical myectomy]], performed at experienced centers,† is recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3.  In [[adult]] [[patients]] with [[obstructive HCM]] who remain severely [[symptomatic]], despite guideline-directed [[management]] and [[therapy]] and in whom [[surgery]] is contraindicated or the [[risk]] is considered unacceptable because of serious [[co-morbidities]] or advanced [[age]], [[alcohol septal ablation]] in eligible [[patients]], performed at experienced centers,† is recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  In [[patients]] with [[obstructive HCM]], earlier ([[NYHA class II]]) [[surgical myectomy]] performed at comprehensive [[HCM]] centers, may be reasonable in the presence of additional [[clinical factors]], including:
a. Severe and progressive [[pulmonary hypertension]] thought to be attributable to [[LVOTO]] or associated [[mitral regurgitation]].
b. [[Left atrial enlargement]] with ≥1 episodes of [[symptomatic]] [[AF]].
c. Poor [[functional capacity]] attributable to [[LVOTO]] as documented on [[treadmill exercise testing]].
d. [[Children]] and young [[adults]] with very high resting [[LVOT]] gradients (>100 [[mm Hg]]).
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  For severely [[symptomatic patients]] with [[obstructive HCM]], [[SRT]] in eligible [[patients]], performed at experienced centers, may be considered as an alternative to escalation of [[medical therapy]] after shared decision-making including [[risks]] and benefits of all [[treatment]] options.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  For [[patients]] with [[HCM]] who are [[asymptomatic]] and have normal [[exercise capacity]], [[SRT]] is not recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7.  For [[symptomatic patients]] with [[obstructive HCM]] in whom [[SRT]] is an option, [[mitral valve replacement]] should not be performed for the sole purpose of relief of [[LVOTO]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for Management of Patients With Non-obstructive HCM With Preserved EF </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[non-obstructive HCM]] with [[preserved EF]] and [[symptoms]] of [[exertional angina]] or [[dyspnea]], [[beta blockers]] or [[non-dihydropyridine calcium channel blockers]] are recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[non-obstructive HCM]] with [[preserved EF]], it is reasonable to add [[oral diuretics]] when [[exertional dyspnea]] persists despite the use of [[beta blockers]] or [[non-dihydropyridine calcium channel blockers]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[non-obstructive HCM]] with [[preserved EF]], the usefulness of [[angiotensin-converting enzyme inhibitors]] and [[angiotensin receptor blockers]] in the [[treatment]] of [[symptoms]] ([[angina]] and [[dyspnea]]) is not well established.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  In highly selected [[patients]] with [[apical]] [[HCM]] with severe [[dyspnea]] or [[angina]] ([[NYHA class III]] or [[class IV]]) despite maximal [[medical therapy]], and with [[preserved EF]] and small [[LV cavity size]] ([[LV end-diastolic volume]] <50 mL/m2 and [[LV stroke volume]] <30 mL/m2), [[apical myectomy]] by experienced [[surgeons]] at comprehensive centers may be considered to reduce [[symptoms]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  In [[asymptomatic patients]] with [[non-obstructive HCM]], the benefit of [[beta blockers]] or [[calcium channel blockers]] is not well established.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|}

====<u> Recommendations for Management of Atrial Fibrillation </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]] and [[clinical]] [[AF]], [[anticoagulation]] is recommended with direct-acting [[oral anticoagulants]] as first-line option and [[vitamin K antagonists]] as second-line option, independent of [[CHA2DS2-VASc score]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] and [[subclinical AF]] detected by internal or external [[cardiac device]] or [[monitor]] of >24 hours’ duration for a given episode, [[anti-coagulation]] is recommended with [[direct-acting oral anticoagulants]] as first-line option and [[vitamin K antagonists]] as second-line option, independent of [[CHA2DS2-VASc score]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[AF]] in whom [[rate control]] strategy is planned, either [[beta blockers]], [[verapamil]], or [[diltiazem]] are recommended, with the choice of agents according to [[patient]] preferences and [[co-morbid conditions]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  In [[patients]] with [[HCM]] and [[subclinical AF]] detected by internal or external device or monitor, of >5 minutes’ but <24 hours’ duration for a given episode, [[anticoagulation]] with [[direct-acting oral anticoagulants]] as first-line option and [[vitamin K antagonists]] as second-line option can be beneficial, taking into consideration duration of [[AF]] episodes, total [[AF]] burden, underlying [[risk factors]], and [[bleeding risk]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  In [[patients]] with [[HCM]] and poorly tolerated [[AF]], a [[rhythm control]] strategy with [[cardioversion]] or [[antiarrhythmic drugs]] can be beneficial with the choice of an agent according to [[AF]] [[symptom]] severity, [[patient]] preferences, and [[co-morbid conditions]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  In [[patients]] with [[HCM]] and [[symptomatic AF]], as part of a [[AF]] [[rhythm control]] strategy, [[catheter ablation]] for [[AF]] can be effective when [[drug therapy]] is ineffective, contraindicated, or not the [[patient]]’s preference.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7.  In [[patients]] with [[HCM]] and [[AF]] who require [[surgical myectomy]], concomitant [[surgical AF]] [[ablation]] procedure can be beneficial for [[AF]] [[rhythm control]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for the Management of Patients With HCM and Ventricular Arrhythmias </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]] and recurrent poorly tolerated [[life]]-threatening [[ventricular tachyarrhythmias]] [[refractory]] to maximal [[anti-arrhythmic]] [[drug therapy]] and [[ablation]], [[heart transplantation]] assessment is indicated in accordance with current listing criteria.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| rowspan="5" bgcolor="LightGray" |2. In [[adults]] with [[HCM]] and [[symptomatic]] [[ventricular arrhythmias]] or [[recurrent]] [[ICD]] [[shocks]] despite [[beta blocker]] use, [[anti-arrhythmic drug therapy]] listed is recommended, with the choice of agent guided by [[age]], underlying [[co-morbidities]], severity of [[disease]], [[patient]] preferences, and balance between [[efficacy]] and [[safety]].
|-
|bgcolor= "PaleTurquoise"; style="text-align:center;|[[Amiodarone]]
C-LD
|-
|bgcolor= "PaleTurquoise"; style="text-align:center;|[[Dofetilide]] 
C-LD
|-
|bgcolor= "PaleTurquoise"; style="text-align:center;|[[Mexiletine]]
C-LD
|-
|bgcolor= "PaleTurquoise"; style="text-align:center;|[[Sotalol]]
C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[children]] with [[HCM]] and recurrent [[ventricular arrhythmias]] despite [[beta blocker]] use, [[anti-arrhythmic]] [[drug therapy]] is recommended, with the choice of agent guided by [[age]], underlying [[co-morbidities]], severity of [[disease]], [[patient]] preferences, and balance of [[efficacy]] and [[safety]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4.  In [[patients]] with [[HCM]] and [[pacing-capable ICDs]], programming [[anti-tachycardia pacing]] is recommended to minimize [[risk]] of [[shocks]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  In [[patients]] with [[HCM]] and recurrent [[symptomatic]] [[sustained monomorphic ventricular tachycardia]], or recurrent [[ICD shocks]] despite optimal [[device]] programming, and in whom [[anti-arrhythmic]] [[drug therapy]] is either ineffective, not tolerated, or not preferred, [[catheter ablation]] can be useful for reducing [[arrhythmia]] burden.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendations for Patients With HCM and Advanced HF </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]] who develop [[systolic dysfunction]] with an [[LVEF]] <50%, guideline-directed [[therapy]] for [[HF]] with [[reduced EF]] is recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] and [[systolic dysfunction]], [[diagnostic testing]] to assess for concomitant causes of [[systolic dysfunction]] (such as [[coronary artery disease]]) is recommended.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[non-obstructive HCM]] and advanced [[HF]] ([[NYHA functional class III]] to [[class IV]] despite guideline-directed [[therapy]]) [[cardio-pulmonary]] [[exercise test]] should be performed to quantify the degree of functional limitation and aid in selection of [[patients]] for [[heart transplantation]] or mechanical [[circulatory support]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In [[patients]] with [[non-obstructive HCM]] and advanced [[HF]] ([[NYHA class III]] to [[class IV]] despite guideline-directed [[therapy]]) or with [[life]]-threatening [[ventricular arrhythmias]] refractory to maximal guideline-directed [[therapy]], assessment for [[heart transplantation]] in accordance with current listing criteria is  recommended.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  For [[patients]] with [[HCM]] who develop s[[ystolic dysfunction]] ([[LVEF]] <50%), it is reasonable to discontinue previously indicated negative [[inotropic agents]] (specifically, [[verapamil]], [[diltiazem]], or [[disopyramide]]).
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  In [[patients]] with [[non-obstructive HCM]] and advanced [[HF]] ([[NYHA functional class III]] to [[class IV]] despite [[GDMT]]) who are candidates for [[heart transplantation]], continuous-[[flow LV]] assist [[device therapy]] is reasonable as a bridge to [[heart transplantation]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7.  In [[patients]] with [[HCM]] and [[LVEF]] <50%, [[ICD placement]] can be beneficial.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|8.  In [[patients]] with [[HCM]] and [[LVEF]] <50%, [[NYHA functional class II]] to [[class IV]] [[symptoms]] despite guideline-direct [[therapy]], and [[LBBB]], [[CRT]] can be beneficial to improve [[symptoms]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

====<u> Recommendations for Sports and Activity </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. For most [[patients]] with [[HCM]], mild- to moderate-intensity recreational [[exercise]] is beneficial to improve [[cardiorespiratory]] [[fitness]], physical functioning, and [[quality of life]], and for their overall [[health]] in keeping with [[physical activity]] guidelines for the general [[population]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. For athletes with [[HCM]], a comprehensive [[evaluation]] and shared discussion of potential [[risks]] of sports participation by an expert provider is recommended..
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. For most [[patients]] with [[HCM]], participation in low-intensity competitive sports is reasonable.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In individuals who are [[genotype]]-positive, [[phenotype]]-negative for [[HCM]], participation in competitive athletics of any intensity is reasonable.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5.  For [[patients]] with [[HCM]], participation in high-intensity recreational activities or moderate- to high-intensity competitive sports activities may be considered after a comprehensive evaluation and shared discussion, repeated annually with an expert provider who conveys that the risk of [[sudden death]] and [[ICD]] [[shocks]] may be increased, and with the understanding that eligibility decisions for competitive sports participation often involve third parties (eg, team [[physicians]], consultants, and other institutional leadership) acting on behalf of the schools or teams.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Red"| [[ESC #Classification of Recommendations|Class III: Harm]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6.  In [[patients]] with [[HCM]], [[ICD placement]] for the sole purpose of participation in competitive athletics should not be performed.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|}

====<u> Recommendations for Occupation in Patients With HCM </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1.For [[patients]] with [[HCM]], it is reasonable to follow Federal Motor Carrier Safety Administration [[cardiovascular disease]] guidelines that permit driving commercial motor vehicles, if they do not have an [[ICD]] or any major [[risk factors]] for [[SCD]] and are following a guideline-directed [[management]] plan.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. For pilot aircrew with a [[diagnosis]] of [[HCM]], it is reasonable to follow Federal Aviation Administration guidelines that permit consideration of multicrew flying duties, provided they are [[asymptomatic]], are deemed [[low risk]] for [[SCD]], and can complete a maximal [[treadmill stress test]] at 85% peak [[heart rate]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. [[Patients]] with [[HCM]] may consider [[occupations]] that require manual [[labor]], heavy lifting, or a high level of [[physical]] performance after a comprehensive [[clinical evaluation]], [[risk stratification]] for [[SCD]], and implementation of guideline-directed [[management]]. Before a shared decision between a [[clinician]] and [[patient]] is reached, the [[clinician]] should convey that [[risks]] associated with the physical requirements of these occupations are uncertain. 
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|}

====<u> Recommendations for Pregnancy in Patients With HCM </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1.For [[pregnant]] [[women]] with [[HCM]] and [[AF]] or other [[indications]] for [[anticoagulation]], [[low-molecular-weight heparin]] or [[vitamin K antagonists]] (at maximum [[therapeutic dose]] of <5 mg daily) are recommended for [[stroke]] prevention.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[pregnant]] [[women]] with [[HCM]], selected [[beta blockers]] should be administered for [[symptoms]] related to [[outflow tract obstruction]] or [[arrhythmias]], with monitoring of [[fetal growth]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In most [[pregnant]] [[women]] with [[HCM]], [[vaginal delivery]] is recommended as the first-choice [[delivery]] option. 
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In affected [[families]] with [[HCM]], [[pre-conceptional]] and [[prenatal]] [[reproductive]] and [[genetic counseling]] should be offered.
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|5. For [[pregnant]] [[women]] with [[HCM]], [[care]] should be coordinated between their [[cardiologist]] and an [[obstetrician]]. For [[patients]] with [[HCM]] who are deemed [[high risk]], [[consultation]] is advised with an expert in [[maternal]]-[[fetal medicine]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|6. For [[women]] with [[clinically stable]] [[HCM]] who wish to become [[pregnant]], it is reasonable to advise that [[pregnancy]] is generally [[safe]] as part of a shared discussion regarding potential [[maternal]] and [[fetal risks]], and initiation of guideline-directed [[therapy]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|7. In [[pregnant]] [[women]] with [[HCM]], [[cardioversion]] for new or [[recurrent AF]], particularly if [[symptomatic]], is reasonable.
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|8. In [[pregnant]] [[women]] with [[HCM]], general or [[epidural anesthesia]] is reasonable, with precautions to avoid [[hypotension]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:Gold"| [[ESC #Classification of Recommendations|Class IIa]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|9. In [[pregnant]] [[women]] with [[HCM]], it is reasonable to perform serial [[echocardiography]], particularly during the second or third [[trimester]] when [[hemodynamic]] load is highest, or if [[clinical symptoms]] develop.
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:SandyBrown"| [[ESC #Classification of Recommendations|Class IIb]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|10. In [[pregnant]] [[women]] with [[HCM]], [[fetal]] [[echocardiography]] may be considered for [[diagnosis]] of [[fetal HCM]] in the context of [[prenatal counseling]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|}

====<u> Recommendations for Patients With Comorbidities </u>====

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|1. In [[patients]] with [[HCM]], adherence to the guidelines on the [[prevention]] of [[atherosclerotic]] [[cardiovascular disease]] is recommended to reduce [[risk]] of [[cardiovascular events]].
|bgcolor= "LightBlue"; style="text-align:center;|C-EO
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|2. In [[patients]] with [[HCM]] who are [[overweight]] or [[obese]], [[counseling]] and comprehensive [[lifestyle interventions]] are recommended for achieving and maintaining [[weight loss]] and possibly lowering the [[risk]] of developing [[LVOTO]], [[HF]], and [[AF]].
|bgcolor= "Turquoise"; style="text-align:center;|B-NR
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|3. In [[patients]] with [[HCM]] and [[hypertension]], [[lifestyle modifications]] and [[medical therapy]] for [[hypertension]] are recommended with preference for [[beta blockers]] and [[non-dihydropyridine calcium channel blockers]] in [[patients]] with [[obstructive HCM]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ESC #Classification of Recommendations|Class I]]
|colspan="0.5" style="text-align:center; background:LightGray"|[[ESC #Level of Evidence|'''Level of Evidence''']]
|-
| bgcolor="LightGray"|4. In [[patients]] with [[HCM]], assessment for [[symptoms]] of [[sleep disordered breathing]] is recommended and, if present, [[referral]] to a [[sleep medicine]] specialist for [[evaluation]] and [[treatment]].
|bgcolor= "PaleTurquoise"; style="text-align:center;|C-LD
|}

==References==