Electrocardiographic precedence with rapid anatomical progression in apical hypertrophic cardiomyopathy: a case report

Deep T-wave inversion (TWI) in the mid- to lateral precordial leads is a recognized electrocardiographic marker of apical hypertrophic cardiomyopathy (ApHCM), although its temporal trajectory is variable. We report a 39-year-old hypertensive, non-athlete male who exhibited stable, low-amplitude biphasic T waves for four years, followed by rapid progression in the fifth year to giant, asymmetric TWI (10 mm). At the onset of this escalation, transthoracic echocardiography revealed relatively increased apical wall thickness compared with basal segments, although still within normative limits, which may represent an early phenotypic cue of ApHCM that was not clinically recognized. Subsequent echocardiography confirmed ApHCM, and cardiac magnetic resonance (CMR) substantiated isolated apical hypertrophy, indicating electro-anatomical conversion during the fifth year despite well-controlled blood pressure. This case highlights that rapid TWI progression following prolonged quiescence should prompt clinical suspicion for ApHCM. Given the potential for false-negative echocardiographic findings, close surveillance and timely CMR are essential for definitive diagnosis.