Prospective Validation of the Prognostic Usefulness of B-Type Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Aortic Regurgitation

Study Questions:

Is there prognostic value of B-type natriuretic peptide (BNP) in patients with severe asymptomatic aortic regurgitation and normal left ventricular (LV) function?

Methods:

A group of 294 consecutive patients with severe asymptomatic organic aortic regurgitation and LV ejection fraction >55% were prospectively evaluated. The first 160 consecutive patients served as the derivation cohort, and the next 134 patients served as a validation cohort. The combined endpoint was the occurrence of either symptoms of congestive heart failure, LV dysfunction, or death at follow-up.

Results:

The endpoint was reached in 45 patients (28%) of the derivation set and in 35 (26%) patients of the validation cohort. Receiver-operator characteristic curve analysis yielded an optimal cutoff point of 130 pg/ml for BNP that was able to discriminate between patients at higher risk in both cohorts. BNP was the strongest independent predictor by multivariate analysis in the derivation set (odds ratio, 6.9; 95% confidence interval, 2.52-17.57; p < 0.0001) and the validation set (odds ratio, 6.7; 95% confidence interval, 2.9-16.9; p = 0.0001).

Conclusions:

Among patients with severe asymptomatic aortic regurgitation and normal LV function, BNP ≥130 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, the authors recommend that BNP assessment should be used in the routine clinical evaluation of these patients.

Perspective:

Chronic compensated severe aortic regurgitation, like chronic compensated severe mitral regurgitation, can progress to LV systolic dysfunction before patients develop symptoms. Existing criteria for intervention among patients with severe aortic regurgitation include symptoms, LV systolic dysfunction, or marked LV enlargement. Although not all asymptomatic patients with chronic severe aortic regurgitation are at risk of developing subclinical LV systolic dysfunction, some patients develop heart failure or LV systolic dysfunction despite care that conforms to current guidelines for intervention. This well-performed study suggests that BNP elevation >130 pg/ml in the asymptomatic patient could serve as an independent reason to consider surgical intervention.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Prognosis, Follow-Up Studies, Biological Markers, Mitral Valve Insufficiency, Cardiology, Cardiomyopathies, Heart Failure, Ventricular Function, Heart Valve Prosthesis Implantation, Atrial Natriuretic Factor


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