This 42-year-old accountant was referred because of ECG abnormalities discovered during a routine life-insurance assessment. He was asymptomatic and exercised regularly without discomfort. His blood pressure was normal. There was a very soft mid-systolic murmur at the left lower sternal border:

• Sinus rhythm
• Left ventricular hypertrophy
• Giant negative T waves in V3 – V6 (consider the possibility of apical hypertrophic cardiomyopathy)

Comment: The combination of left ventricular hypertrophy and the giant negative T waves in the precordial leads in an asymptomatic active patient suggested the possibility of apical hypertrophic cardiomyopathy (ACM). The diagnosis was confirmed by echocardiography, that demonstrated the characteristic spade-like configuration of the LV cavity due to the hypertrophy of apical region.  (Eriksson, M.J. et al; Longterm outcome in patients with apical hypertrophic cardiomyopathy, J Am Coll Cardiol 2002; 39:638 – 645 )