Introduction: Apical hypertrophic cardiomyopathy (HC) is a rare type of cardiomyopathy characterized by hypertrophy involving the left, and sometimes right ventricular apex. It is more prevalent in the Asian population where it accounts for 25% of patients with HC. In the non-Asian population, it accounts for 1 to 10% of hypertrophic cardiomyopathy cases (1, 2). The echocardiographic diagnostic criteria for apical HC include a demonstration of apical hypertrophy, apical wall thickness ≥ 15 mm, and a ratio of maximal apical to posterior wall thickness ≥ 1.5 (2). We present a case of apical HC in a 68-year-old patient.

Case report: 68-year-old female patient was brought to the emergency department with symptoms of chest pain and dyspnea. 12-lead electrocardiogram (ECG) showed sinus rhythm with negative T waves in the anterolateral and inferior leads and voltage criteria for left ventricular hypertrophy. Her bloodwork was unremarkable, except for slightly increased values of N-terminal brain natriuretic peptide which was 1107 pg/ml. The high sensitive troponin T level was 36.1 ng/L. She was admitted to the Cardiac Intensive Care Unit for further observation and diagnostics. The coronary angiogram was normal. Ventriculography revealed a spade-like-shaped left ventricular cavity (Figure 1). Echocardiography confirmed the same shape of the left ventricle due to hypertrophy of apical segments of the LV with maximum wall thickness of 19 mm (Figure 2). The global longitudinal strain was reduced in apical and middle segments (Figure 3) and LVEF was 61%. The patient was scheduled for cardiac magnetic resonance imaging, but she refused the imaging due to claustrophobia.

Conclusion: Although apical HC is not so common in the European population, it should be considered as a differential diagnosis in patients with typical ECG changes. These patients can present with a broad range of symptoms, including palpitations, dyspnea, syncope, exercise intolerance, and chest pain. Although it is not associated with increased cardiovascular mortality, up to one-third of patients with apical HC can develop serious complications, e.g., arrhythmias, myocardial infarction, and stroke.