Correspondence

randomized, controlled clinical trials that sup- Mercedes SotosPrieto, Ph.D.

port the health benefits of greater adherence to Ohio University
healthy dietary patterns and lower risk of all- Athens, OH
msotosp@hsph.harvard.edu
cause and cardiovascular disease mortality.1 Al-
though residual confounding cannot be complete- ShilpaN. Bhupathiraju, Ph.D.
ly ruled out in observational studies, we carefully Harvard Medical School
controlled for both baseline factors and lifestyle Boston, MA
changes and for the presence of coexisting ill- FrankB. Hu, M.D., Ph.D.
nesses. The consistency of our findings across Harvard T.H. Chan School of Public Health
various subgroups (according to baseline factors Boston, MA
and changes in health conditions) suggests that Since publication of their article, the authors report no fur-
the results are unlikely to be due to changes in ther potential conflict of interest.
physiologic health.
1. Scientific report of the 2015 Dietary Guidelines Advisory
Gaye et al. raise an interesting point. In our Committee. Washington, DC:Department of Health and Human
view, the approach to studying trajectories in diet Services, Department of Agriculture, February 2015 (https://
quality will add valuable information by classify- health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific
-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf).
ing people into different groups, depending on 2. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Med-
their trajectory of diet-quality changes over time. iterranean-style diet on the need for antihyperglycemic drug
Esposito et al. describe the pooled results of therapy in patients with newly diagnosed type 2 diabetes: a ran-
domized trial. Ann Intern Med 2009;151:306-14.
randomized, controlled trials2,3 that showed the 3. Esposito K, Marfella R, Ciotola M, et al. Effect of a Mediter-
positive effects of a Mediterranean diet interven- ranean-style diet on endothelial dysfunction and markers of vas-
tion on surrogate biomarkers of longevity. We cular inflammation in the metabolic syndrome: a randomized
trial. JAMA 2004;292:1440-6.
believe that these findings provide further sup-
port for the biologic plausibility of our findings. DOI: 10.1056/NEJMc1710523

Beating, Fast and Slow

To the Editor: Jani et al. (July 6 issue)1 describe
a 52-year-old man who presented with a recent
history of exertional chest discomfort and dys-
pnea. Cardiac positron-emission tomographic per-
fusion scanning with intravenous dipyridamole
was performed as the initial diagnostic test, and
the findings showed a reversible myocardial per-
fusion defect in the inferior wall. The patient re-
ceived a prescription of atenolol, and severe brady-
ischemia a diagnosis that led to the inappro-
priate and near disastrous prescription of a beta-
blocker. This case underscores the point that in
the pursuit of the correct diagnosis, less can
indeed be more.
Peter Bogaty, M.D.
Quebec Heart and Lung Institute
Quebec, QC, Canada
peter.bogaty@fmed.ulaval.ca

arrhythmia developed after he took the first
dose. Subsequent investigation, including coro-
nary angiography, led to the diagnosis of giant-
cell myocarditis. Nuclear perfusion imaging with
No potential conflict of interest relevant to this letter was re-
ported.
1. Jani SM, Nallamothu BK, Cooper LT, Smith A, Fazel R. Beat-
ing, fast and slow. N Engl J Med 2017;377:72-8.

dipyridamole is a nonphysiological and relatively DOI: 10.1056/NEJMc1710015

expensive diagnostic approach, and it may not be
specific for the detection of myocardial ischemia,
as shown by the incorrect diagnosis in this case.
Neither the authors in their commentary nor the
expert clinician discussant mention that a simple
electrocardiographic treadmill exercise test would
have directly addressed the patients exertional
symptoms, would probably have identified chro-
notropic insufficiency as their cause, and would
not have suggested the presence of myocardial
The authors reply: We agree with Bogaty that
exercise stress testing with cardiac imaging would
have been the preferred approach and more ap-
propriate than vasodilator stress testing in our
patient.1 Exercise stress testing provides valuable
prognostic information that is based on exercise
duration, heart-rate recovery, ST-segment response,
exercise-induced hypotension, and chronotropic
incompetence. However, our patients pretest

n engl j med 377;13nejm.org September 28, 2017 1305

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 notices
probability for coronary artery disease was inter-
mediate to high, and stress testing with imaging
is recommended in this context because of its
higher diagnostic accuracy relative to exercise
electrocardiography alone.1
It is also worth noting that the onset of heart
block in cases of giant-cell myocarditis can be
sudden. Therefore, chronotropic incompetence
may not have been present on the day of the
stress test in our patient, particularly because
the electrocardiogram showed no evidence of a
clinically significant atrioventricular block and
there was a normal heart-rate response to vaso-
dilator stress.
Reza Fazel, M.D.
Brigham and Womens Hospital
Boston, MA
rfazel@bwh.harvard.edu
Andrew Smith, M.D.
Emory University Hospital
Atlanta, GA
BrahmajeeK. Nallamothu, M.D., M.P.H.
University of Michigan Medical School
Ann Arbor, MI
Since publication of their article, the authors report no fur-
ther potential conflict of interest.
1. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/
AATS/PCNA/SCAI/STS guideline for the diagnosis and manage-
ment of patients with stable ischemic heart disease: a report of
the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines, and the Ameri-
can College of Physicians, American Association for Thoracic
Surgery, Preventive Cardiovascular Nurses Association, Society
for Cardiovascular Angiography and Interventions, and Society
of Thoracic Surgeons. Circulation 2012;126(25):e354-e471.
DOI: 10.1056/NEJMc1710015
Correspondence Copyright 2017 Massachusetts Medical Society.
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