This 62-year-old woman with mild well controlled hypertension and good exercise tolerance was first discovered to have an abnormal ECG two years ago during a routine assessment. The ECG findings are unchanged. She has been referred to the cardiac clinic because of a brief episode of syncope:

• Sinus rhythm with sinus arrhythmia
• Left ventricular hypertrophy with ST depression and giant negative T waves in the left chest leads
• Consider the possibility of apical hypertrophic cardiomyopathy