• heart disease

The recommendation in current guidelines that aortic valve replacement (AVR) be performed in adults with symptomatic severe aortic stenosis (AS) is based on solid evidence. However, it is unclear whether adults with asymptomatic severe AS also should be considered for elective AVR. This uncertainty is based on several considerations including the difficulty in recognising that symptoms are present and might be due to AS in older adults who often have multiple comorbidities, the concern that waiting for symptoms might be associated with irreversible cardiac changes, and the (although small) risk of sudden death. In addition, perhaps it makes sense to perform AVR before the patient is older and sicker, given the inevitable progression to symptoms once severe AS is present. On the other hand, both surgical and transcatheter AVR are associated with mortality and morbidity and the bioprosthetic valve is subject to deterioration, starting at the time of implantation.

In this issue of Heart, Nakatsuma and colleagues1 hypothesised that serum B-type natriuretic peptide (BNP) level would allow accurate risk stratification of adults with asymptomatic severe AS. In a large Japanese registry of adults with severe AS, data from the 387 patients with no symptoms and normal left ventricular systolic function showed that higher BNP levels were associated …