@article{Marwaha:2026:10.1186/s44156-026-00123-5,
author = {Marwaha, SK and Basu, J and Bhatia, R and Maclachlan, H and Fyyaz, S and Esteban, MTT and Behr, ER and Finocchiaro, G and Malhotra, A and Prasad, S and Gati, S and Papadakis, M and Sharma, S},
doi = {10.1186/s44156-026-00123-5},
journal = {Echo Res Pract},
title = {Unravelling the grey zone: submaximal-to-peak stress echocardiography enhances diagnostic accuracy in differentiating early dilated cardiomyopathy from physiological adaptation.},
url = {http://dx.doi.org/10.1186/s44156-026-00123-5},
volume = {13},
year = {2026}
}

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TY  - JOUR
AB  - BACKGROUND: Participation 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. OBJECTIVES: We 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. METHODS: Of 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. RESULTS: Resting 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 singl
AU  - Marwaha,SK
AU  - Basu,J
AU  - Bhatia,R
AU  - Maclachlan,H
AU  - Fyyaz,S
AU  - Esteban,MTT
AU  - Behr,ER
AU  - Finocchiaro,G
AU  - Malhotra,A
AU  - Prasad,S
AU  - Gati,S
AU  - Papadakis,M
AU  - Sharma,S
DO  - 10.1186/s44156-026-00123-5
PY  - 2026///
SN  - 2055-0464
TI  - Unravelling the grey zone: submaximal-to-peak stress echocardiography enhances diagnostic accuracy in differentiating early dilated cardiomyopathy from physiological adaptation.
T2  - Echo Res Pract
UR  - http://dx.doi.org/10.1186/s44156-026-00123-5
UR  - https://www.ncbi.nlm.nih.gov/pubmed/42289761
VL  - 13
ER  - 

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