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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%.
My concern is that I haven't had any cardiac symptoms during rigorous exercise, but the literature seems to be scary when describing my echocardiogram results. I don't understand how such a dramatic change occurred in one year. 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.
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.
The next step is a cardiologist with expertise in this condition in a dedicated HCM center, if possible. 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. Very high-intensity weight lifting exercises should be avoided, as these will provoke obstruction.