Moderate-intensity exercises, such as walking, cycling, and swimming at a recreational pace, are recommended.<\/p>\n
Dear Dr. Roach: I\u2019m a physically active 75-year-old man. I\u2019m 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.<\/p>\n
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\u2019s 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%.<\/p>\n
My concern is that I haven\u2019t had any cardiac symptoms during rigorous exercise, but the literature seems to be scary when describing my echocardiogram results. I don\u2019t understand how such a dramatic change occurred in one year. Do I need to reduce my daily exercise? \u2014 T.B.<\/p>\n
There\u2019s 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.<\/p>\n
The 2026 echocardiogram shows that there\u2019s a large pressure gradient from the apex of your heart to the valve opening, confirming obstruction in the mid-cavity. I don\u2019t believe that this condition happened within a year. It\u2019s common that the condition\u2019s missed by an echocardiogram, which I suspect happened in 2025. It\u2019s estimated that the condition is missed 50% of the time by echocardiograms, and I don\u2019t mean to suggest that the echocardiographer made a mistake.<\/p>\n
If the echocardiographer would\u2019ve had you perform a Valsalva maneuver (a way to increase pressure in the chest and abdomen, such as keeping your airway closed and \u201cbearing down\u201d with your abdominal muscles), they would\u2019ve seen the pressure gradient. Although I\u2019m sure that your condition progressed between 2025 and 2026, the usual pattern is a slow progression over a decade or so.<\/p>\n
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\u2019ve 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\u2019ve never seen used) are sometimes prescribed for people with symptoms.<\/p>\n
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.<\/p>\n
I\u2019d 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.<\/p>\n