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Purpose: To evaluate the echocardiographic and clinical characteristics of hypertrophic cardiomyopathy (HCM) patients who develop heart failure (CHF).Methods and results: Two hundred and ten patients with HCM from our cardiomyopathy clinic were analyzed regarding symptoms of CHF, left ventricular (LV) systolic and diastolic function. Sixteen patients (8%) had an hypokinetic LV (HLV) defined as LVEF< 50%.Thirty seven (18%) had advanced diastolic dysfunction (ADD), defined as a pseudonormal or a restrictive left ventricular filling pattern according to the ASE guidelines.On the table we compare patients with HLV to patients with normal LV function and patients with ADD to the patients without ADD.Patients with HLV had a higher prevalence of ADD(75% vs.13%, p=0.0001), of family history of HCM (94% Vs. 46%(p=0.0001), younger age of disease onset (28±14 vs.38±18 years old,p=0.03) and a longer follow up time(25±12 Vs 13±12 years, p<0.0001). NYHA class was worse in the 7 HLV patients with a non-dilated LV (LVEDD≤55mm, p=0.01).Patients with ADD had a higher prevalence HLV(36% vs 2%, p<0.0001), of of family history of HCM (68% Vs.46%, p=0.02) and a longer follow up time (18±4 years Vs.12±12 years, p=0.01) but a similar age of disease onset. Patients with both ADD and HLV had a worse NYHA class(3±0.8) and higher mortality(58%).Conclusion: The individual presence of HLV and ADD, and especially their combination is associated with long standing disease, advanced CHF and adverse prognosis in HCM.