LAUSR

We read the interesting letter of K. Pafili and N. Papanas commenting on our recent paper on autonomic testing [1]. We appreciated that they reached somewhat similar conclusions in a previous work [2]: i.e., the association of HRV on Valsalva manoeuvre (VM) and on lying to standing (LS) is the most reliable tests for autonomic dysfunctions, although we found VM more sensitive than LS, in contrast to what they found. However, we need to underline an important feature of our work: it is based on the ability of each test to recognize the presence “in the real world” of autonomic neuropathy, i.e., documented by the relief of postural hypotension. This marks an important difference from other previously published papers cited by K. Pafili and N. Papanas which, however, were based on “self-controlled” calculations within the five Ewing’s tests: i.e., comparing the sensitivity (and specificity) of each test with the other tests in cross correlations within the battery itself in a questionable “closed loop”. Moreover, the clinical utility of VM and LS which we found pivotal in autonomic testing is confirmed by the paper of May and Arildsen [3] which shows the high independent predicting mortality value of VM and LS, while the deep breathing test results useless; just on the line and confirming what recently has come from the DIAD study, as mentioned in our paper [4, 5]. Therefore, at least one question arises from our paper and other recent evidences: is it necessary to use the deep breathing test anymore? Hence, following our approach, the diagnosis in cardiovascular autonomic neuropathy results, we would say, simpler and clearer too.