The distribution of the coronary arteries in the myocardium runs from the epicardium inwards. If hypertrophy is severe, the coronary arteries can no longer ensure a sufficient supply of oxygen to the entire width of the wall. Relative ischemia can occur at rest, but is more likely on exertion. Clinically, stress-induced angina pectoris or dyspnea can occur. In severe hypertrophy, this ischemia can even lead to a connective tissue transformation of the heart muscle, that is to myocardial fibrosis. This is not uncommon in patients with hypertrophic cardiomyopathy, where the myocardium thickness can be more than 30mm. Diseases leading to left ventricular hypertrophy often cause diastolic dysfunction, with increased left ventricular filling pressures. Again, the high pressures lead to poorer perfusion of the ventricular myocardium.