Increased B-type natriuretic peptide is associated with an abnormal blood pressure response to exercise in asymptomatic aortic stenosis

Pelt, Niels C van; Kerr, Andrew; Legget, Malcolm E.; Pasupati, Sanjeevan; Whalley, Gillian A.; Wong, Selwyn; Zeng, Irene; Stewart, Ralph

doi:10.1016/j.ijcard.2007.07.172

Cited by 22 publications

(14 citation statements)

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“…Elevated BNP has been correlated with decreased aortic valve area, increased aortic jet velocity, increased left ventricular mass, and decreased exercise capacity. 12 Valve replacement has been shown to be associated with a decline in BNP, which is consistent with the expected hemodynamic effects of valve replacement. 13 Serial measurements of BNP have demonstrated larger increases in BNP in patients who go on to develop symptoms as compared with those who remain asymptomatic.…”

Section: Article See P 69supporting

confidence: 64%

“…BNP elevation, reflecting increased LV wall stress, may be useful in indicating subtle left ventricular pathology in asymptomatic patients. [11][12][13][14] An association between aortic stenosis and BNP was demonstrated by Lim et al, 11 who studied 70 patients with asymptomatic and symptomatic severe aortic stenosis. Elevated BNP levels were correlated strongly with poor clinical outcomes in all patients.…”

Section: Article See P 69mentioning

confidence: 91%

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Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Coglianese

Davidoff

2009

Circulation

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A lthough the annual risk of cardiovascular mortality has been well described for individuals with symptomatic aortic stenosis, the morbidity and mortality for those with asymptomatic severe aortic stenosis is not as well known. Currently the American Heart Association/American College of Cardiology recommends a "watchful waiting" strategy for those with asymptomatic aortic stenosis. 1 This involves clinical examinations every 6 to 12 months and annual echocardiograms; however, it is unclear what to do with these data in the patient who remains asymptomatic. The asymptomatic patient is generally not referred for aortic valve replacement surgery until the development of symptoms (unless concurrent coronary artery bypass grafting is required or if systolic dysfunction develops). Article see p 69Approximately 30% of asymptomatic patients will develop symptoms (angina, heart failure, syncope) within 2 years of diagnosis. 2,3 For those patients who do not develop symptoms, the risk of sudden cardiac death is less than 1% per year, assuming that patients are well monitored for the development of symptoms. 2,3 Although angina and syncope are relatively easy symptoms to elicit, manifestations of heart failure may be subtle. This is particularly true because many of these patients are elderly and attribute reduced exercise capacity to be part of the normal aging process or "slowing down." Vigilance and careful attention to a patient's history are important components of the regular evaluation of patients with aortic stenosis. However, even careful attention to the history may not predict sudden death in patients with severe aortic stenosis. The reluctance to perform surgery earlier than necessary is driven by the morbidity of cardiac surgery and a mortality rate for aortic valve surgery of approximately 3% to 5%, even in patients younger than 70 years. 4 Thus for truly asymptomatic patients, the risk of potential complications like sudden cardiac death and irreversible myocardial dysfunction must be weighed against the risk of surgery. Given the possibility of these outcomes before the development of overt symptoms, investigators have sought to find a reliable way in which to risk stratify patients with asymptomatic aortic stenosis into those who will derive benefit from surgery before symptom development and those who will not. A comprehensive objective approach that could facilitate decision making in such patients has long been sought but has been elusive.In this issue of Circulation, Monin et al 5 describe a scoring system for patients with asymptomatic severe aortic stenosis based on the premise that both the state of the valve and the ventricle must be considered when assessing risk in asymptomatic patients. The risk of valve-specific factors such as aortic valve area, aortic valve calcification, transvalvular gradients, and peak aortic velocity have been well described, but the prognostic value of each or a combination of anatomic and functional valve information has not been consistently predictive of outcome. 6 ...

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Section: Article See P 69supporting

confidence: 64%

Section: Article See P 69mentioning

confidence: 91%

Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Coglianese

Davidoff

2009

Circulation

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“…Van Pelt et al demonstrated that AS patients with an increase in systolic BP of ≤20 mmHg during exercise had higher plasma levels of BNP than patients with an increase in systolic BP >20 mmHg. (Van Pelt et al, 2008) BNP was a superior predictor of abnormal blood pressure response than AVA, LV EF, diastolic function, and LV mass index. These observations support the use of BNP for monitoring asymptomatic patients or patients with equivocal symptoms, as well as patients who are unable to exercise.…”

Section: Natriuretic Peptides and Functional Status Of As Patientsmentioning

confidence: 80%

“…In contrast, levels of natriuretic peptides correlate with the New York Heart Association (NYHA) symptom class and echocardiographic measures of LV dysfunction and therefore may be useful in indicating subtle LV pathology in asymptomatic patients. (Lim, 2004;Van Pelt, 2008;Weber, 2005;Gerber, 2005) Importantly, natriuretic peptide levels are on average higher in patients with NYHA class II symptoms than in patients with class I symptoms. This supports the notion that natriuretic peptide levels could be used to discriminate between early heart failure symptoms and normal effort tolerance (Figure 4).…”

Section: Natriuretic Peptides and Functional Status Of As Patientsmentioning

confidence: 98%

Natriuretic Peptides in Severe Aortic Stenosis - Role in Predicting Outcomes and Assessment for Early Aortic Valve Replacement

Lin¹,

Stewart²

2011

Aortic Stenosis - Etiology, Pathophysiology and Treatment

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“…BNP is a member of the natriuretic peptide family, and is a potent vasodilator with mitogenic, hypertrophic and pro-inflammatory properties that is upregulated in hypertensive diseases. An association between BNP increase and an abnormal increase in SBP in response to exercise has been reported in patients with asymptomatic aortic stenosis [Van Pelt et al 2008]. The role of BNP during exercise has been studied in overt hypertensive patients before, during and after submaximal exercise, and in the recovery period.…”

Section: Introductionmentioning

confidence: 99%

Exercise testing in hypertensive patients for assessing the cardiovascular protective potential of antihypertensive drugs

Brunel

Baschiera

Cífková

2013

Therapeutic Advances in Cardiovascular Disease

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Exercise testing is an established noninvasive tool in cardiology used to diagnose and guide treatment in individuals with suspected or confirmed coronary artery disease. Owing to the wealth of information it provides, exercise testing is also being utilized to evaluate prehypertensive stages, characterize hypertension, assess tolerance to exercise and the efficacy of antihypertensive therapies, and predict target organ damage and cardiovascular risk. The literature on exercise tolerance tests is relatively limited since these studies are difficult to conduct although they represent a valuable test for evaluating the benefits of antihypertensive therapies beyond their blood-pressure-lowering efficacy at rest or during exercise. Such a setting can be immensely useful for the evaluation and for the differentiation of treatments, especially in patients with evident rises in systolic blood pressure and with concomitant diseases, who are at higher risk of stroke. Exercise-induced increase in systolic blood pressure from rest to peak exercise should therefore be used as the primary efficacy variable. There is growing evidence that central pressure is a better predictor for cardiovascular risk than peripheral blood pressure, since this variable takes into account the overall effect of vascular aging and increased arterial stiffness that age and other concomitant diseases may induce. It is also important to include central aortic blood pressure and biomarkers of hypertension and cardiac disease in the overall assessment.

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Increased B-type natriuretic peptide is associated with an abnormal blood pressure response to exercise in asymptomatic aortic stenosis

Cited by 22 publications

References 22 publications

Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Predicting Outcome in Patients With Asymptomatic Aortic Stenosis

Natriuretic Peptides in Severe Aortic Stenosis - Role in Predicting Outcomes and Assessment for Early Aortic Valve Replacement

Exercise testing in hypertensive patients for assessing the cardiovascular protective potential of antihypertensive drugs

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