Evidence map›Paper›PMID 42289761›Full record

ArticleEcho research and practice2026

Unravelling the grey zone: submaximal-to-peak stress echocardiography enhances diagnostic accuracy in differentiating early dilated cardiomyopathy from physiological adaptation.

Sarandeep K Marwaha, Joyee Basu, Raghav Bhatia, Hamish Maclachlan, Saad Fyyaz, Maria Teresa Tome Esteban, Elijah R Behr, Gherardo Finocchiaro, Aneil Malhotra, Sanjay Prasad and 3 more

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Article in Echo research and practice, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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1 · What the graph read from it

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4 · The record

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5 · Who and what money

Authors and funding

13 authors.

Sarandeep K MarwahaCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Joyee BasuCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Raghav BhatiaCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Hamish MaclachlanCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Saad FyyazCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Maria Teresa Tome EstebanCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Elijah R BehrCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Gherardo FinocchiaroCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Aneil MalhotraManchester Metropolitan University, Manchester, UK.
Sanjay PrasadRoyal Brompton and Harefield NHS Foundation Trust, London, UK.
Sabiha GatiRoyal Brompton and Harefield NHS Foundation Trust, London, UK.
Michael PapadakisCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK.
Sanjay SharmaCardiovascular Research Institute, City St George's, University of London, Cranmer Terrace, London, SW17, UK. sasharma@sgul.ac.uk.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundParticipation in regular endurance exercise may be associated with physiological left ventricular (LV) dilatation and concomitant low resting LV ejection fraction (LVEF), a phenotype indistinguishable from early dilated cardiomyopathy (DCM) on resting imaging alone and termed the "grey zone". Stress echocardiography has emerged as a potential arbiter and has been proposed to resolve this dilemma.

objectivesWe evaluated the diagnostic accuracy of stress echocardiography in distinguishing physiological from pathological LV dilatation and assessed whether incorporating submaximal-to-peak contractile reserve improved discriminatory value in athletes in the grey zone.

methodsOf the 182 athletic individuals, 62 control athletes with an enlarged LV and normal LVEF, 58 athletic DCM individuals, and 62 grey zone athletes underwent stress echocardiography using a semi-supine bicycle. In addition to the ability to augment LVEF ≥ 10% from rest to maximal exercise, we evaluated the ability to augment LVEF from submaximal exercise (80% of maximal heart rate) to peak exercise.

resultsResting LV dimensions did not differ significantly amongst the groups. Control athletes had higher resting LVEF than grey zone athletes and DCM individuals (62.1% vs 52.1% and 53.1%; p=<0.001). Control and grey zone athletes showed greater ΔLVEF from rest to peak exercise than DCM individuals (21% and 19.2% vs 4.9%; p < 0.001). Most control (98.3%) and grey-zone athletes (90.3%) achieved a ΔLVEF ≥ 10% from rest to peak exercise compared with 20.6% of athletic DCM individuals. Control and grey zone athletes also revealed a mean increase in LVEF from submaximal to peak exercise of 7.5% and 3.8%, respectively, whereas DCM individuals showed a mean LVEF decline of -4.3% (p < 0.001). Although 20.6% of DCM individuals demonstrated a ΔLVEF ≥ 10% from rest to peak, only a single DCM individual augmented LVEF from submaximal to peak exercise. Failure to increase LVEF ≥ 10% from rest to peak exercise identified DCM with 79.4% sensitivity and 98.3% specificity. Combining this inability with a failure to augment LVEF from submaximal to peak exercise improved the sensitivity to 98.2% and specificity to 98.4%.

conclusionReliance on rest-to-peak augmentation of ≥10% alone risks misclassification. Introducing submaximal-to-peak augmentation enhances diagnostic precision by identifying virtually all individuals with DCM while preserving specificity.

Indexed as

AthletesDilated cardiomyopathyGrey zoneLeft ventricular ejection fractionStress echocardiogram

Identifiers

PMID42289761
PMCPMC13267247

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.