European Heart Journal Advance Access originally published online on June 7, 2006
European Heart Journal 2006 27(15):1884-1885; doi:10.1093/eurheartj/ehl078
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Dilated cardiomyopathy and coronary flow reserve: reply
CNR
Institute of Clinical Physiology
Via. G. Moruzzi 1
56124 Pisa
Italy
CNR
Institute of Clinical Physiology
Via. G. Moruzzi 1
56124 Pisa
Italy
Tel: +39 050 315 2374
Fax: +39 050 315 2374
E-mail address: rosas{at}ifc.cnr.it
We thank Tona for the interest in our work. We fully agree that some patients with myocarditis might have been included in our patient population because the identification of them was based only on the clinical picture. Therefore, we excluded those with a clinical picture consistent with acute myocarditis; nonetheless, those patients with a long-lasting history of LV dysfunction (>2 years) were included in the analysis independent of the aetiology of the non-ischaemic dilated cardiomyopathy. This explains the number of patients with hypertension and diabetes included in the analysis. We employed the standard criteria of the WHO for the definition of dilated cardiomyopathy:1 ‘Dilated cardiomyopathy is characterized by dilatation and impaired contraction of the left ventricle or both ventricles. It may be idiopathic, familial/genetic, viral and/or immune, alcoholic/toxic, or associated with recognized cardiovascular disease in which the degree of myocardial dysfunction is not explained by the abnormal loading conditions or the extent of ischemic damage. Histology is nonspecific. Presentation is usually with heart failure, which is often progressive. Arrhythmias, thromboembolism, and sudden death are common and may occur at any stage’. Regarding the need to perform a myocardial biopsy to absolutely exclude the presence of patients with myocarditis, we refer to the 2005 AHA/ACC Guidelines2 in which no recommendation is reported for the routine use of endomyocardial biopsy for the diagnostic assessment of patients with dilated cardiomyopathy. A recent review on this complex issue concluded that outside scientific studies there is no indication to perform myocardial biopsy in these patients.3 The lack of a recommendation for the routine use of such an invasive procedure has also safety reasons: the risk of serious complications is around 1%, which is not negligible and should be, therefore, justified and outweighed by a high rate of diagnostic accuracy. But this is not the case because many patients with a non-ischemic cardiomyopathy show non-specific changes on biopsy (including hypertrophy, cell loss, and fibrosis), and it has not been established conclusively how biopsy findings (even when positive) affect patient management.3
In relation to the cut-off value employed, 2 is a widely accepted criterion of normality as extensively discussed with review of the existing literature.4 During the revision process of the manuscript, the ROC analysis we performed was not considered an appropriate approach by the statistical reviewer due to the censored nature of the endpoint. Nonetheless the best cut-off value identified by the ROC analysis was 1.8, which is consistent with our previous results in patients with coronary artery disease.5
The nature of the study design did not allow us to perform CFR in the follow-up, but the improvement of CFR in certain diseases with coronary microvascular dysfunction would have a positive impact on prognosis, representing a new therapeutic target. We agree with Tona and with Zamorano and Mateos6 that this will be an important challenge for future studies in the field.
References
- Richardson P, McKenna W, Bristow M, Maisch B, Mautner B, O'Connell J, Olsen E, Thiene G, Goodwin J, Gyarfas I, Martin I, Nordet P. (1996) Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task force on the definition and classification of cardiomyopathies. Circulation 93:841–842.
[Free Full Text] - Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web Site. http://www.acc.org/clinical/guidelines/failure//index.pdf.
- Kuhn H, Lawrenz T, Beer G. (2005) Indication for myocardial biopsy in myocarditis and dilated cardiomyopathy. Med Klein 100:553–561.[CrossRef]
- Rigo F. (2005) Coronary flow reserve in stress-echo lab. From pathophysiologic toy to diagnostic tool. Cardiovasc Ultrasound 3:8.[CrossRef][Medline]
- Rigo F, Cortigiani L, Pasanisi E, Richieri M, Cutaia V, Celestre M, Raviele A, Picano E. (2005) The additional prognostic value of coronary flow reserve on left anterior descending artery in patients with negative stress echo by wall motion criteria. A transthoracic vasodilator stress echo study. Am Heart J 149:684–689.
- Zamorano J and Mateos BR. (2006) Prognosis of coronary flow reserve: a new therapeutic target? Eur Heart J 27:1266–1267.
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