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A 13 year old boy was investigated for recurrent exertional syncope. Chest x ray showed a globular cardiac silhouette and 12 lead ECG suggested left ventricular hypertrophy with strain pattern. Transthoracic echocardiography (TTE) revealed basal septal hypertrophy with systolic anterior motion (SAM) of the mitral valve. A diagnosis of hypertrophic cardiomyopathy (HCM) was made and β blockers were started. Twenty years later, the patient reported symptoms of gradually worsening …