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We agree with many of the comments made by Yamada et al., namely that the ECG and NTproBNP are fundamental tests used in the diagnosis of heart failure and that as tests become cheaper they become more cost-effective. We further agree that our data show that hand-held echocardiography gives the greatest sensitivity, ECGs give intermediate sensitivity, and NTproBNP normal range cuts off the worst sensitivity in detecting left ventricular systolic dysfunction (LVSD). We also agree that as screening sensitivity falls, some subjects with the screened-for condition will fail to have it diagnosed. Although we clearly stated that the screening programmes described would miss cases of LVSD, we did not make it clear that this was a function of screening sensitivity, an important point that we are pleased Yamada et al. have emphasized. Thus, NTproBNP-driven screening would leave more subjects with LVSD undiagnosed than ECGor hand-held echocardiographydriven screening. However, as ECG-driven screening has much lower specificity (thus higher false positive rates) and hand-held echocardiography costs more than NTproBNP per test, our conclusion that NTproBNP or ECG screening prior to hand-held echocardiography prior to traditional echocardiography is the most cost-effective strategy, at both current test costs and future likely test costs, remains correct. Furthermore, despite its lower sensitivity, NTproBNPdriven screening might be justifiable in practice, as subjects with normal NTproBNP levels have extremely low cardiac morbidity and mortality whatever their left ventricular function, although long-term follow-up of our subjects would be required to confirm this. Finally, we agree that if the price of hand-held echocardiography approached that of the ECG, hand-held echocardiography would clearly become the screening method of choice. However, whether this would ever happen is unclear, and furthermore were this to happen then whether enough fully trained sonographers would be available to accurately screen for LVSD using this technology is also unclear, a major potential future issue.

What is the most useful and cost-effective strategy to screen for left ventricular systolic dysfunction in clinical practice?: reply