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In Fabry cardiomyopathy, little is known about the interaction between its key feature of myocardial replacement fibrosis and changes in resting, Holter, and exercise electrocardiography (-ECG).Resting ECG, 24-h Holter ECG, and exercise ECG were performed in 95 patients (50 women) with Fabry disease, staged using cardiac magnetic resonance imaging to measure left ventricular fibrosis. With resting ECG, T alterations were seen in patients with cardiac fibrosis, while time intervals and rhythm were unchanged (except for a longer QRS duration in patients with severe fibrosis). All patients with severe fibrosis showed T inversion, ST alteration, or both. With Holter ECG, maximum and minimum heart rate did not differ with fibrosis severity. Patients without fibrotic tissue showed less ventricular premature beats (VPB) (median 5/24 h) compared to those with mild (median 11/24 h) or severe fibrosis (median 115/24 h; P 0.05, respectively). Fibrosis was a strong predictor of VPB burden (rOur data suggest that cardiac replacement fibrosis is responsible for repolarization abnormalities on resting ECG and increased VPB with Holter ECG. During exercise ECG, advanced cardiomyopathy is characterized by chronotropic incompetence with limitations on blood pressure and heart rate increase.

Nowadays, the scenary surrounding tests for the detection of myocardial ischemia is crowded and somewhat confusing: a Disneyland of diagnos-tic approaches with a variety of stresses (physical, electrical, and phar-macologic) in combination with all the available technologies: from well-established tools such as the electrocardiogram, to the more recent imag-ing techniques (nuclear cardiology, echocardiography), up to the latest, more sophisticated and expensive ones (magnetic resonance, ultrafast computerized tomography, positron emission tomography) allowing noninvasive insight into myocardial function and metabolism in a polychrome, three-dimensional, almost mesmerizing fashion [1]. The ex-plosion of imaging has selected two new entities of cardiologic fauna: the “stunned” and the “hibernated” cardiologist.

The value of an exercise test, as well as any other diagnostic procedure, is dependent on the quality of the test itself as well as the knowledge of the physician who ordered the test. The indications for the test should be clear, while the physician should be able to correlate the test results with other information on the patient.