BACKGROUND: Athlete’s heart and apical hypertrophic cardiomyopathy (ApHCM) share similar features of increased voltage and deep T wave inversions (TWI) on electrocardiogram (EKG). It is very important to perform a detailed transthoracic echocardiogram (TTE) to make this important distinction.

CASE: We present a case of an asymptomatic, athletic, 53-year-old man who was evaluated for an abnormal EKG showing deep TWI (15 mm) across the anterior leads (A). He cycled >100 miles per week. An initial TTE showed mildly increased left ventricular (LV) wall thickness, LV ejection fraction of 67% and average global longitudinal strain of -23.8% (B, C) with normal diastology.

DECISION-MAKING: In light of an ambiguous diagnosis as to whether the patient had an athlete’s heart or ApHCM, he was referred to our HCM clinic. Repeat TTE with focused apical imaging revealed an apical thickness of 22 mm without apical pouch; global and regional (apical) strain was reduced consistent with ApHCM (D, E). Mildly abnormal diastolic dysfunction was noted. Cardiac magnetic resonance imaging confirmed focal asymmetric thickening of the apex measuring 20 mm (F) with 10% mid-myocardial delayed enhancement (G). In this case, foreshortening of the LV apex on the initial echo led to falsely normal echocardiographic findings and, hence, deviation from the correct diagnosis.

CONCLUSIONS: Our case emphasizes the importance of a meticulously performed TTE with focused imaging of the apex in order to arrive at the correct diagnosis of ApHCM.