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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.
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. Although I’m sure that your condition progressed between 2025 and 2026, the usual pattern is a slow progression over a decade or so.
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. Your medication regimen is likely to be changed to a beta-blocker, and new treatments (such as cardiac myosin inhibitors, which I’ve never seen used) are sometimes prescribed for people with symptoms.
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 (which require a Valsalva maneuver) should be avoided, as these will provoke obstruction in the heart.
I’d be cautious about high-intensity aerobic activities, such as competitive sports, until your cardiologist gives you approval. You should be particularly careful to avoid dehydration. I recommend that you maintain the adequate fluid intake with a sports drink that has the appropriate electrolytes.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu. (c) 2026 North America Syndicate Inc.
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