ECG Diagnosis: Apical Hypertrophic Cardiomyopathy

Kaiser Permanente, The Permanente Medical Group, The Permanente Federation

Joel T Levis, MD, PhD, FACEP, FAAEM

Perm J 2013 Spring; 17(2):84

Kaiser Permanente, The Permanente Medical Group, The Permanente Federation 

Apical hypertrophic cardiomyopathy (HCM) is an atypical phenotype of nonobstructive HCM with an indistinguishable histology.1 In Japan this apical variant constitutes approximately 25% of patients with HCM, although it is uncommon in other parts of the world, accounting for only 2% of patients with HCM.1 The electrocardiogram in apical HCM typically shows repolarization changes and giant (>10 mm), inverted T waves in the anterolateral leads (particularly in leads V4 and V5).2,3 Transthoracic echocardiography is the initial test of choice in making the diagnosis. Patients with apical HCM can present with chest pain, dyspnea, palpitations, or syncope.1 Patients with this condition may remain asymptomatic, with the condition detected by chance as a result of an abnormal electrocardiogram.3 In general, the condition carries a benign prognosis, although complications including ventricular tachycardia, atrial fibrillation, apical myocardial infarction, and apical aneurysm can occur in rare instances.1

1.    Bankar RN, Hemadri A, Nasar A, Abson CP. A man with chest pain and interesting electrocardiogram. The Internet Journal of Internal Medicine [serial on the Internet] 2007 [cited 2011 Jul 27]; 7(1): [about 4 p]. Available from: DOI:
 2.    Moon JC, Fisher NG, McKenna WJ, Pennell DJ. Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with non-diagnostic echocardiography. Heart 2004 Jun;90(6):645-9. DOI:
3.    Zachariah S, Davis GK. A patient with recurrent syncope. Postgrad Med J 2004;80(940):117,120-1. DOI:


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