The underlying mechanisms may be attributed to hyperglycemia, which induces diffuse myocardial fibrosis in HCM patients through multiple pathways, including oxidative stress, pro-inflammatory state, growth factor secretion, neurohumoral activation, deposition of advanced glycation end-products, and activation of the renin-angiotensin-aldosterone system (29). This evidence concerns the gene REN and Myocardial fibrosis.