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Background Heterozygous familial hypercholesterolemia (heFH) is a genetic disorder leading to premature coronary artery disease (CAD). We hypothesized that the subclinical pathophysiologic consequences of hypercholesterolemia may be detected before the occurrence of clinically overt CAD by stress testing and myocardial strain imaging. Patients-methods We evaluated the treadmill tests (ETTs) of 46 heFH men without known arterial hypertension/diabetes mellitus/vasculopathy like CAD and of 39 healthy men matched for age, baseline systolic/diastolic blood pressure (BP) and heart rate (HR), using Bruce protocol. Global longitudinal strain (GLS) of the left ventricle (LV) additionally to ejection fraction was obtained. Results heFH men reached a significantly higher peak systolic and diastolic BP compared to controls (p = 0.002 and p, Highlights • Stress testing and myocardial strain imaging may detect subclinical consequences of heterozygous familial hypercholesterolemia. • Male patients with heFH underwent exercise treadmill testing and speckle-tracking echocardiography. • Male heFH patients showed a higher rise in systolic/diastolic blood pressure during exercise treadmill testing than healthy controls. • Global longitudinal strain of heFH males is slightly impaired compared with healthy subjects.