What Echo Could Not See: Silent Apical HCM Revealed by MRI in a Competitive Athlete

Abstract

Aims: Apical hypertrophic cardiomyopathy (ApHCM) poses a significant diagnostic challenge in athletes due to its subtle presentation and the technical limitations of echocardiography. This case aims to highlight the diagnostic limitations of routine pre-participation screening in athletes and emphasize the pivotal role of cardiac MRI in detecting silent ApHCM. Introduction: Apical hypertrophic cardiomyopathy is an uncommon phenotype of hypertrophic cardiomyopathy that may remain clinically silent and is frequently under detected by standard screening tools. In athletes, deep T-wave inversions, which can be the earliest and sometimes only marker of the disease, should prompt further evaluation even when echocardiography appears normal. Advanced imaging modalities, particularly cardiac MRI, play a crucial role in accurately identifying apical pathology. Case Presentation: A 29-year-old elite competitive football player, completely asymptomatic, underwent routine pre-participation evaluation. Physical examination was unremarkable and transthoracic echocardiography was normal. Resting ECG revealed deep T-wave inversions in the anterolateral and inferior leads with electrical left-ventricular hypertrophy. The discordance between the profoundly abnormal ECG and the normal echocardiogram prompted further investigation with cardiac MRI, which demonstrated apical hypertrophy with a base-to-apex wall-thickness ratio >1.2, maximal apical thickness of 15 mm, and a characteristic ace-of-spades left-ventricular configuration. Late gadolinium enhancement imaging showed no myocardial fibrosis. A maximal exercise test showed normal functional capacity with no arrhythmias. Discussion: This case illustrates how ApHCM can evade detection during routine athletic screening due to the limited apical visualization of echocardiography. Current guidelines therefore recommend cardiac MRI when repolarization abnormalities are unexplained. Deep T-wave inversions remain a key early marker and warrant comprehensive investigation. Cardiac MRI offers superior spatial resolution and tissue characterization, allowing definitive diagnosis and prognostic assessment through fibrosis evaluation. Risk stratification in athletes should integrate MRI findings, exercise testing, and clinical profile to guide shared decision-making regarding continued sports participation. Conclusion: In conclusion, abnormal ECGs in athletes must not be dismissed. Silent ApHCM may be missed during routine evaluation, and ECG abnormalities should prompt advanced imaging even when echocardiography is normal. Cardiac MRI is essential for accurate diagnosis and risk assessment. In low-risk, asymptomatic athletes, continued participation may be acceptable within a framework of informed consent and structured long-term surveillance.