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Background: clinical usefulness of echo-Doppler parameters of left ventricular (LV) diastolic dysfunction in hypertrophic cardiomyopathy (HCM) is presently debated.AIM: to assess the value of TDI imaging, and in particular of E/E' ratio, in predicting the clinical course of patients with HCM. Methods and results: Eighty HCM patients consecutively observed in our Department from 2000 to 2010 (60% males, mean age 43±19 years) and studied by echo-Doppler and TDI were prospectively included in the study and followed-up for a combined clinical end-point (cardiovascular death, heart transplantation or septal myectomy). E/E' ratio was evaluated by ratio of peak E wave velocity at pulsed Doppler transmitral curve and of E' wave at basal septal TDI. The patients were divided into 2 groups: - group 1: E/E'>15 (35 patients/44%); - group 2: E/E'≤15 (45 patients/66%). In comparison with group 2, patients of group 1 were significantly older (51±18 vs 37±19, 0.001), showed more frequently atrial fibrillation (18% vs 2%, p=0.014), a more severe LV hypertrophy (interventricular septum 22±7 mm vs 18±5 mm, p=0.003; posterior wall 14±4 mm vs 12±3 mm), a larger left atrium area (29±9 cm2 vs 22±8 cm2) and a more frequent systolic anterior motion (43% vs 20%, p=0.03). During a mean follow-up of 46±95 months, 9 patients (11%) reached the combined clinical end-point; event-free survival rates were 80% vs 96% in group 1 vs group 2, respectively (p=0.03). Conclusions: Evaluation of E/E' ratio at diagnosis is an important tool in identifying patients with a particularly poor prognosis. Elevated values of E/E'(> 15) are probably related to a more advanced stage of the disease.