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The Authors’ reply We are grateful to Dr Stuart1 for his interest in our paper.2 We agree entirely that our dilated cardiomyopathy (DCM) cohort were indeed highly selected. Most individuals with DCM do not have the capacity to exercise intensively and would not fit in the differential diagnosis of an athlete’s heart with borderline or mildly reduced left ventricular (LV) ejection fraction. For the purposes of this study, we sought to identify individuals with a mild form of DCM who were motivated to and could exercise intensively for a prolonged …

ObjectiveDistinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction MethodsThirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.ResultsLarger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p63% in 92% grey-zone athletes compared with 17% patients with DCM (p11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.ConclusionComprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.

LV torsion during exercise in patients with coronary artery disease (CAD) is not well known. Circumferential strain (CS) and left ventricular (LV) torsion (Tor) have not been evaluated during ischemia in these patients. We aimed to assess the effect of ischemia during exercise echocardiography (ExE) on CS and Tor. We studied a group of 73 patients with true positive ExE results (Ischemic group: ischemia plus an abnormal coronary angiogram) and a matched control group of 66 patients with negative ExE and either normal coronary angiography or low post-test probability of CAD. Basal rotation (Rot) and apical rotation and basal and apical CS were studied by speckle tracking at rest and exercise. Apical CS and apical and basal Rot values were similar between groups at rest, except basal CS which was already worse in the ischemic group. At exercise, all rotational and CS parameters were impaired in the ischemic in comparison with the control group (basal CS: −18 ± 5 vs. −25 ± 7 %, p

Recommendations for testing in patients with low pretest probability of coronary artery disease differ in guidelines from no testing at all to different tests. The aim of this study was to assess the value of exercise echocardiography (ExE) to define outcome in this population.A retrospective analysis was conducted of 1,436 patients with low pretest probability of coronary artery disease (15%) who underwent initial ExE. Overall mortality, major adverse cardiac events (MACEs), defined as cardiac death or nonfatal myocardial infarction, and revascularization during follow-up, were assessed. Ischemia (development of new wall motion abnormalities with exercise) and fixed wall motion abnormalities were measured.The mean age was 50 ± 12 years. Resting wall motion abnormalities were seen in 13 patients (0.9%) and ischemia in 108 (7.5%). During follow-up, 38 patients died, 10 of cardiac death (annualized death rate, 0.39%); 20 patients had MACEs (annualized MACE rate, 0.21%); and 48 patients (29 with ischemia) underwent revascularization (annualized revascularization rate, 0.51%). The number and percentage of MACEs in the abnormal and normal ExE groups were similar (two [1.7%] vs 18 [1.4%], P = .70), as was the annualized MACE rate (0.31% vs 0.21%, P = .50). Peak left ventricular ejection fraction exhibited a nonsignificant trend for predicting MACEs (P = .11). The number of studies needed to detect an abnormal finding was 12.6 and to detect a patient with extensive ischemia was 26.1.ExE offers limited prognostic information in patients with low pretest probability of coronary artery disease. The small number of abnormal findings on ExE and low event rates and the large number of studies needed to detect an abnormal finding limit further the value of imaging in this population.

Resumen Antecedentes y objetivo El sincope es una entidad frecuente y con un diagnostico complejo. El rendimiento del Holter-ECG 24 h en este contexto no esta bien definido. Nuestro objetivo fue evaluar su capacidad diagnostica y pronostica en estos pacientes. Pacientes y metodo Estudio retrospectivo de 6.006 pacientes consecutivos remitidos a nuestra unidad para la realizacion de Holter-ECG 24 h por sincope. Se registraron los hallazgos diagnosticos y aquellos hallazgos anormales potencialmente relacionados con una causa arritmica de sincope. El objetivo pronostico fue un combinado de muerte o necesidad de implante de dispositivo (marcapasos o desfibrilador implantable) a un ano. Resultados En total, 242 pacientes (4%) presentaron hallazgos diagnosticos y 472 (7,9%) tuvieron algun hallazgo anormal. En 328 casos fue necesario el implante de un dispositivo a un ano, pero hasta un 66% de estos enfermos no tenian ningun hallazgo relevante en el Holter. Un total de 564 pacientes presentaron el episodio combinado, incluyendo el 36,8% de pacientes con hallazgos diagnosticos y el 8,2% sin hallazgos diagnosticos. Conclusiones El Holter-ECG 24 h presenta un rendimiento diagnostico y pronostico limitados en pacientes no seleccionados con sincope.