Most symptomatic HCM patients don't show their obstruction lying on the examination table🫀 A new EHJIMP review by Keen & Desai from Cleveland Clinic is a masterclass in why your imaging protocol, beyond just your imaging modality, determines whether you catch it. The stress test choice matters more than most workups reflect: * Upright treadmill can unmasks obstruction in >90% of patients at peak exercise. * Semi-supine bicycle → only ~40% * Bicycle allows continuous imaging through exertion, capturing the timing of obstruction onset and dynamic MR. Treadmill mostly captures recovery. It's a genuine trade-off, not a clear winner — the choice should be individualized. * CMR remains uniquely good at catching what echo misses: small apical aneurysms (prognostically significant — arrhythmia and thrombus risk) and fibrosis burden via late gadolinium enhancement. But even LGE quantification isn't standardized — the two dominant methods (n-SD thresholding vs. full-width-half-maximum) can disagree enough to change how a patient gets risk-stratified. Also worth flagging: AI-derived, demographic-adjusted LVH thresholds are showing that fixed wall-thickness cutoffs may under-diagnose HCM in women and smaller patients — a bias baked into decades of "normal" reference values. Zooming out, the review isn't arguing for one best modality. It frames HCM imaging as a workflow problem: echo as the foundation, CMR for phenotyping and fibrosis, CT and PET deployed selectively when there's real diagnostic uncertainty — not sequentially by default. Full open-access review at the #EHJIMP on /10.1093/ehjimp/qyag099 Genuinely curious where others land on this — treadmill or semi-supine bicycle your default for suspected latent LVOT obstruction, and has that choice ever changed your management?