An overlooked diagnosis on transthoracic echocardiography: apical hypertrophic cardiomyopathy

Apical hypertrophic cardiomyopathy (HCM) may be overlooked during routine echocardiography. A 54-year-old male patient with dyslipidemia and positive family history presented with atypical chest pain. The 12-lead electrocardiogram showed increased QRS voltage and deep T-wave inversions in precordial leads. Transthoracic echocardiography performed with poor echocardiographic windows demonstrated normal findings. Coronary angiography showed normal coronary arteries. Left ventriculography revealed a spade-like deformity (ace of spades), typical for apical HCM. Cardiac magnetic resonance imaging confirmed the diagnosis.