In this episode of In the Thick of It, Dr. Madeline Smoot talks with Dr. Alex McNamara to discuss the complexities of managing refractory symptoms in patients with hypertrophic cardiomyopathy (HCM). The conversation highlights the distinction between obstructive and non-obstructive symptoms, emphasizing the importance of provocative testing—such as cardiopulmonary exercise testing (CPET) and gold-directed Valsalva maneuvers—to unmask "labile" obstruction that resting echoes might miss. They explore the evolving role of cardiac myosin inhibitors and the potential impact of GLP-1 agonists on obesity-related symptom burden. Additionally, Dr. McNamara provides insights into identifying red flags beyond obstruction, including primary mitral valve disease and the early stages of restrictive or "burnt-out" HCM.