We thank Drs. Claridge and Greaves for their interest in our work. They properly state that acquisition of images of good quality is a challenge in obese patients, particularly during exercise echocardiography (ExE), and wonder how many patients in our study were overweight or obese. These data are available for 112 of the 116 patients included in our study. Among them, 46 (41%) were obese (body mass index ≥ 30 kg/m 2 ) and 53 (47%) overweight (body mass index, 25–29.99 kg/m 2 ). Only 13 patients (12%) had body mass indexes < 25 kg/m 2 . Therefore, although it was not our intention, this study could also be considered research on obese and overweight patients. However, this is quite the norm in patients with known or suspected coronary artery disease, as Drs. Claridge and Greaves claim.
We did not include these data in our report, because our goal was to compare the ischemic burden using the three approaches: peak treadmill ExE, post-treadmill ExE, and peak supine bicycle ExE. Accordingly, we selected only patients expected to perform adequately with both methods (treadmill and supine bicycle ExE). This selection led us to include fitter patients (regardless of obesity or overweight), fewer women, and fewer elderly patients. In our view, almost every patient who walks into the stress echocardiography room is able to walk on a treadmill, provided that the exercise echocardiographic protocol is suitable for that patient. However, not all patients know how to exercise on a bicycle, and stopping pedaling and pedaling backward are frequent problems, particularly in older patients. In addition, the more frequent cause of stopping exercise on a bicycle is muscle pain, and adequate quadriceps musculature is necessary to achieve enough load to develop ischemia or complete the test. Therefore, again, elderly patients, women, and less fit patients may not be good candidates for bicycle ExE, not because they have poor acoustic windows but because of expected low feasibility.
We have previously shown high feasibility of peak treadmill ExE, as well as superior diagnostic and prognostic capabilities in comparison with imaging after exercise. In these nonselected patients, image quality was similar at peak exercise and after exercise, except for the parasternal views. However, these same segments can be adequately visualized in the apical views; therefore, a successful peak imaging examination may rely on apical images alone.
Having stated this, we agree that a study of the feasibility of peak treadmill and peak supine bicycle exercise in a wider spectrum of patients would shed more light on the issue of how to deal with these patients.