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Heartbeat: Highlights from this issue
  1. Catherine M Otto
  1. Correspondence to Professor Catherine M Otto, Division of Cardiology, University of Washington, Seattle, WA 98195, USA;

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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).

Figure 1

Comparison of the event-free survival curves for median peak-exercise B-type natriuretic peptide (BNP) level in the subsets of patients with high and low resting BNP level in patients with severe aortic stenosis (n=157). This figure shows the event-free survival curves for the composite end-point of death or aortic valve replacement in the subsets of patients with low versus high resting BNP level (red vs blue curves, respectively), according to low versus high peak-exercise BNP (full vs dotted lines, respectively). The symbols indicate the significant difference between groups: *p<0.05 versus ‘Low resting—Low peak-exercise BNP level’; ¶p<0.05 versus ‘Low resting—High peak-exercise BNP level’; §p<0.05 versus ‘High resting—Low peak-exercise BNP level’. The numbers at the bottom of the graph represent the number of patients …

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