Apical outpouching, including wall motion abnormalities and aneurysms, has been described in apical hypertrophic cardiomyopathy (ApHCM). Between 1976 and 2006, 193 patients with ApHCM (120 men; overall mean age, 61 ± 17 years) were evaluated. Apical outpouching was found in 29 patients (15%) and in 22 of the 78 patients (28%) imaged with contrast echocardiography. Six patients had apical aneurysms, and 23 patients had hypokinesis with apical dilatation but no wall thinning. Apical outpouching was more common in patients with diastolic gradients out of the apex (P < .001), corrected QT interval prolongation (P < .001), increased apical wall thickness (P = .01), and family histories of sudden cardiac death (P = .03). Sudden cardiac death, resuscitated cardiac arrest, or discharge of an automated internal cardiac defibrillator, or a combination, was observed in 11 patients (6%) during follow-up. Atrial fibrillation (28%), ventricular tachycardia (20%), and stroke (11%) were also relatively common in this study. No difference was observed in overall mortality rate comparing patients with ApHCM with and without apical outpouching. Similarly, no differences were found in the rates of sudden cardiac death, resuscitated cardiac arrest, and discharge of an automated internal cardiac defibrillator. The impact of true aneurysms was not assessed in this study. Cardiac complications appear commonly in patients with ApHCM, but they did not seem to be related to apical outpouching in the present analysis.