Background: In chronic heart failure augmented wall stress leads to increased energy demand. Supply, however, may be reduced due to coronary vasoconstriction and endothelial dysfunction. This might lead to a mismatch between demand and supply. In the present study we further explored the effect of increased demand during dobutamine stress echocardiography. Ž Methods and results: Sixteen patients with idiopathic dilated cardiomyopathy mean age 44 " 13 years, New York Heart . Association class II᎐III, mean left ventricular ejection fraction 0.27" 0.10 underwent dobutamine stress echocardiography Ž . 5᎐40 grmin per kg bodyweightq atropine if required . Wall motion and thickening was assessed in 16 segments using a Ž . four-point scale. Eleven patients 69% showed regions with worsening of wall motion or a biphasic response during dobutamine infusion. Of the remaining five patients one patient did not show any wall motion changes and one patient showed a partial improvement while only in three patients wall motion improvement in the whole heart was found. Conclusion: A majority of patients with idiopathic dilated cardiomyopathy showed decreased wall motion during increased demand, i.e. ischemia-like myocardial contractile responses during dobutamine stress echocardiography. These findings further support the concept that an energy mismatch between demand and supply might play a pathophysiological role in idiopathic dilated cardiomyopathy. ᮊ