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Dynamic left ventricular outflow tract (LVOT) obstruction is a distinctive finding on echocardiography and often supports a diagnosis of hypertrophic obstructive cardiomyopathy (HOCM). It is also a clinical entity in its own right and is reproducible with stress. We describe a case of dynamic outflow obstruction in an elderly man with classical exertional symptoms. Echocardiography was used to demonstrate a variable gradient, with imaging performed at rest and following physical exertion. We will review the pathophysiological changes seen in this condition, both in terms of cardiac structure and the physics of fluid dynamics. Medical treatment is centered around a meaningful understanding of these changes, but there are also surgical and ablative options available. Device therapy with an implantable cardioverter-defibrillator (ICD) is the mainstay of HOCM treatment, particularly when ventricular arrhythmias are evident. A risk stratification for sudden cardiac death from hypertrophic cardiomyopathy is imperative in case by case management.