Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease of cardiac muscle which can present with myriad functional and clini- cal manifestations. When symptoms and left ventricular outflow gradients are present, it is primarily treated with pharmacologic agents. For refractory patients, dual chamber pacing has been proposed; by altering timing and site of cardiac electrical activation, obstruction may be improved. Results of non-randomized and randomized trials have shown an average gradient reduction of 50%. However, pres- sure gradient reduction within the left ventricular outflow tract (LVOT) has not translated into improved objective functional measure- ments, even though subjective parameters may improve. Dual chamber pacing cannot be recommended as primary treatment for obst- ruction except in a subset of patients who are elderly or have significant comorbidities that preclude surgery. However, many patients will now receive implantable cardioverter-defibrillators (ICD) which will include both right atrial and right ventricular leads. This will al- low DDD pacing which may be utilized for symptom palliation. Future investigations will determine if alternate forms of pacing, including left atrial or left ventricular pacing, may improve objective measures in these patients.