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DEAR DR. ROACH: I'm a physically active 75-year-old man. I'm taking atorvastatin, losartan and amlodipine. During my annual physical in January 2025, my physician noticed a heart murmur. I had an echocardiogram done in February 2025 that showed a dilated proximal ascending aorta, measuring at 4.1 centimeters. It was 3.9 centimeters in January 2024.
In February 2026, I had a repeat echocardigoram to check my ascending aorta, and it stabilized at 4.1 cm. However, it showed that there's a mid-cavitary gradient of 44 mmHg at rest that increased to 99 mmHg with a Valsalva maneuver. Also noted were a normal left ventricular size and mild basal septal hypertrophy, with hyperdynamic systolic function and a left ventricular ejection fraction greater than 70%.
Do I need to reduce my daily exercise?
-- T.B.
ANSWER: There's a lot to explain here, but the most important point is that you have a condition called hypertrophic cardiomyopathy (HCM), most likely the subtype with mid-cavitary obstruction. Essentially, the asymmetrical enlargement in the septum (the part of the heart muscle that separates the left ventricle from the right ventricle) causes obstruction inside the heart, preventing the blood in the apex of the heart from flowing through to the aortic valve.
The 2026 echocardiogram shows that there's a large pressure gradient from the apex of your heart to the valve opening, confirming obstruction in the mid-cavity. I don't believe that this condition happened within a year. It's common that the condition's missed by an echocardiogram, which I suspect happened in 2025. It's estimated that the condition is missed 50% of the time by echocardiograms, and I don't mean to suggest that the echocardiographer made a mistake.
If the echocardiographer would've had you perform a Valsalva maneuver (a way to increase pressure in the chest and abdomen, such as keeping your airway closed and "bearing down" with your abdominal muscles), they would've seen the pressure gradient.
The next step is a cardiologist with expertise in this condition in a dedicated HCM center, if possible. An MRI scan with gadolinium might be recommended to further characterize your cardiac anatomy and physiology. Years ago, surgery would've been considered the first-line treatment for obstruction, but most people do well with medical therapy.
Some exercises are beneficial, but others are to be avoided. Moderate-intensity exercises, such as walking, cycling, and swimming at a recreational pace, are recommended. I recommend that you maintain the adequate fluid intake with a sports drink that has the appropriate electrolytes.