Mihos and coworkers present an interesting report on the impact of apical aneurysm in patients with apical hypertrophic cardiomyopathy (ApHCM). They reference the literature that shows it occurs in 10-15% of patients with ApHCM and that its presence confers a 3-fold increase in HCM-related death or life-saving aborted HCM-related events, and that it is considered a marker of increased risk of sudden death1-2. Their study shows differences in myocardial work efficiency and global wasted work between patients with and without aneurysms. The question is whether the aneurysm caused the differences or are the aneurysms caused by the differences?