Pseudonormalization of negative T wave during stress test in asymptomatic patients without ischemic heart disease: a clue to apical hypertrophic cardiomyopathy?

Introduction: Generally, apical hypertrophic cardiomyopathy (ApHCM) shows a negative T wave on an electrocardiogram (ECG), which waxes and wanes during the clinical course. However, some patients with ApHCM just have negative T waves and show no obvious diagnostic evidence on their echocardiography, so the diagnosis of ApHCM cannot be confirmed or is delayed for several years in many cases.

Case Report: In our study, 2 males in their 50s showed negative T waves on their ECG precordial leads, but no diagnosis was confirmed for over 10 years, despite all efforts. Both patients showed pseudonormalization of the negative T wave during a stress test using a treadmill and dobutamine. They were finally diagnosed with ApHCM confirmed by cardiac magnetic resonance (MR).

Discussion: Pseudonormalization of the negative T wave during a stress test is a quite rare phenomenon, particularly in the general population, and cardiac MR is very costly and inaccessible. Thus, when such an ECG pattern is observed without evidence of other pathology, the possibility of ApHCM should be kept in mind and the performance of cardiac MR may be considered. Furthermore, this pseudonormalization pattern could also be one possible explanation for the waxing and waning of the negative T wave during the course of ApHCM.