Reply:

Potential conflict of interest: Nothing to report. We appreciate the letter by Koshy et al. We agree with the authors that blunted contractile response to stress is a pathophysiologically relevant criterion in the assessment for cirrhotic cardiomyopathy (CCM). We also agree that, unfortunately, the lack of a universal, precise definition of this criterion limits its utility in daily clinical practice, at this time. Because of this, we elected to include blunted contractile response to stress as a measure that requires further validation in the contemporary CCM criteria (see original article, Table 1).1 While finding a clinically applicable, well‐validated definition of blunted contractile response to stress is important, frequently prescribed beta blockers in these patients may continue to be a limitation to applying this criterion unless beta blockers are held, at the provider’s discretion, for 24‐72 hours before stress testing, depending on the agent used. The goal of redefining CCM is to improve understanding of the prognosis and potential interventions for this phenomenon, aiming to prevent progressive cardiac dysfunction, specifically heart failure (HF). HF is categorized mainly into two entities: HF with preserved ejection fraction (i.e., diastolic dysfunction) and HF with reduced ejection fraction (i.e., systolic dysfunction). This categorization has its own therapeutic and prognostic implications. The diagnostic tools recommended by the most recent cardiology guidelines2 to determine the type of heart failure were adapted by the CCM Consortium to develop the contemporary criteria for CCM. These tools have been well validated for assessment of cardiac muscle dysfunction universally in the general population and are feasible to use in daily clinical practice, and the measurement cutoffs for abnormal values have been well defined. To further research in this area, an improved definition of CCM is (hopefully) only the starting point. We would like to emphasize that the contemporary CCM criteria represent one of the means to detect subclinical left ventricular dysfunction and decreased contractile reserve, but they might not be the only tool. There are other surrogates, including functional assessments such as that of contractile response to stress, which will need additional study and validation. We hope that future research will help elucidate validated, clinically applicable characterization of other criteria to implement as diagnostic and prognostic measures for CCM to improve outcomes in these patients.

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