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Current guidelines recommend aortic valve replacement in patients with severe symptomatic aortic stenosis (AS). However, symptom onset often is insidious so that some patients attribute their declining exercise capacity to normal aging rather than to valve obstruction. Furthermore, AS is a progressive disease; patients with severe obstruction who are currently asymptomatic will soon transition to overt symptoms. The Editor's Choice in this issue of Heart is an original research article by Dr Capoulade and colleagues (see page 1606) who hypothesized that asymptomatic AS patients at risk of imminent symptom onset could be identified by the combination of resting and exercise serum B-type natriuretic peptide (BNP) levels. In a prospective study of 211 asymptomatic AS patients followed for a mean of 1.8±1.3 years, there were 7 deaths and 97 aortic valve replacements. Both resting and exercise BNP were predictive of event free survival with the combination of both providing incremental prognostic value (figure 1).
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