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“OBJECTIVES We sought a method for any reader to quantify the limit, imposed by variability, to sustainably observable R-2 between any baseline predictor and response marker. We then apply this to echocardiographic measurements of mechanical dyssynchrony and response.\n\nBACKGROUND Can mechanical dyssynchrony markers strongly predict ventricular remodeling by biventricular Panobinostat order pacing (cardiac resynchronization therapy)?\n\nMETHODS First, we established the mathematical depression

of observable R-2 arising from: 1) spontaneous variability of response markers; and 2) test-retest variability of dyssynchrony measurements. Second, we contrasted published R-2 selleckchem values between externally monitored randomized controlled trials and highly skilled single-center studies (HSSCSs).\n\nRESULTS Inherent variability of response markers causes a contraction factor in R-2 of 0.48 (change in left ventricular ejection fraction [Delta LVEF]), 0.50 (change in end-systolic volume [Delta ESV]), and 0.40 (change in end-diastolic volume [Delta EDV]). Simultaneously, inherent variability of mechanical dyssynchrony markers causes a contraction factor of between 0.16 and 0.92 (average, 0.6). Therefore the combined contraction factor, that is, limit on sustainably observable R-2 between mechanical

dyssynchrony markers and see more response, is similar to 0.29 (Delta LVEF), similar to 0.24 (Delta ESV), and similar to 0.30 (Delta EDV). Many R-2 values published in HSSCSs exceeded these mathematical limits; none in externally monitored trials did so. Overall, HSSCSs overestimate R-2 by 5- to 20-fold (p = 0.002). Absence of bias-resistance features in study design (formal enrollment and blinded measurements) was associated with more overstatement

of R-2.\n\nCONCLUSIONS Reports of R-2 > 0.2 in response prediction arose exclusively from studies without formally documented enrollment and blinding. The HSSCS approach overestimates R-2 values, frequently breaching the mathematical ceiling on sustainably observable R-2, which is far below 1.0, and can easily be calculated by readers using formulas presented here. Community awareness of this low ceiling may help resist future claims. Reliable individualized response prediction, using methods originally designed for group-mean effects, may never be possible because it has 2 currently unavailable and perhaps impossible prerequisites: 1) excellent blinded test-retest reproducibility of dyssynchrony; and 2) response markers reproducible over time within nonintervened individuals. Dispassionate evaluation, and improvement, of test-retest reproducibility is required before any further claims of strong prediction. Prediction studies should be designed to resist bias.