Great progress has been made in the diagnosis and treatment of hypertrophic cardiomyopathy (HCM) since its first pathologic description in the 1950s. However, it remains a complex entity to manage, with a myriad of possible presentations, ranging from no symptoms to florid heart failure or sudden cardiac death (SCD). In this chapter, we describe important different clinical scenarios in HCM, starting from patient presentation, and then “pausing” at a key decision-making juncture. We utilize this “pause” to describe the evidence behind the final decision, which is explained at the end of each case.