This 46-year-old man is discovered to have a cardiomyopathy 3 years ago when he applied for life insurance. He remains moderately active and cycles frequently without discomfort:

• Marked sinus bradycardia, 41/min
• Left ventricular hypertrophy with QRS widening and repolarizarion abnormality
• Marked ST elevation in V1-V4 (reciprocal changes of left ventricular hypertrophy, previously noted)

The ECG shows ST elevation in aVR and V1-V4. These changes are reciprocal to the ST depression in the left and posterior leads facing the left ventricle, and can mimic a myocardial infarction due to occlusion of the main left coronary artery. In fact, in this case the computerized ECG-interpretation program gave a diagnosis of acute myocardial infarction.

His echocardiocardiogram showed asymmetrical hypertrophic cardiomyopathy with a marked gradient (105 mm Hg) at the level of the left ventricle’s outflow tract.