title: Severe autonomic failure as a predictor of mortality in aortic valve stenosis.
abstract: BACKGROUND
  Identification of new risk markers in aortic valve stenosis (AS) is of great interest. Here, we hypothesized that the presence of severe autonomic failure (SAF) is an important prognostic marker in both, symptomatic patients undergoing invasive treatment for severe AS, and in asymptomatic patients with severe AS who were primarily treated conservatively.
  
  
  METHODS
  We prospectively enrolled 300 patients with severe AS (aortic valve area<1.0 cm2 or mean aortic gradient>40 mmHg) in sinus rhythm. All patients underwent a 24-h Holter recording for assessment of heart rate turbulence (HRT) and deceleration capacity (DC). Patients with both, abnormal DC and HRT were considered to suffer from SAF.
  
  
  RESULTS
  The first hypothesis was tested in 216 symptomatic patients who underwent successful aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI). During follow-up of 2 years, 29 of these patients died. SAF was the strongest independent predictor of mortality (hazard ratio 5.6, 95% confidence interval 2.6-12.0; p<0.001) with 2-year mortality rates of 50.0% and 10.7% in SAF-positive and SAF-negative patients, respectively (p<0.001). The second hypothesis was tested in 71 patients, who were asymptomatic at study entry and for whom a primarily conservative treatment strategy was proposed. During follow-up, 10 of these patients died. SAF also predicted death in asymptomatic patients with 2-year mortality rates of 52.4% and 8.7% in SAF-positive and SAF-negative patients, respectively (p=0.010).
  
  
  CONCLUSIONS
  SAF is a strong and independent predictor of mortality in symptomatic and asymptomatic patients with severe AS.
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany.
authors.forename: Christine S
authors.initials: CS
authors.lastname: Zuern
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany; Munich University Clinic, Ludwig-Maximilians University, Munich, Germany and DZHK (German Centre for Cardiovascular Research).
authors.forename: Konstantinos D
authors.initials: KD
authors.lastname: Rizas
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Eick
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany.
authors.forename: Marie-Isabel
authors.initials: MI
authors.lastname: Vogtt
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany.
authors.forename: Boris
authors.initials: B
authors.lastname: Bigalke
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany.
authors.forename: Meinrad
authors.initials: M
authors.lastname: Gawaz
authors.affiliation: Abteilung Innere Medizin III, Department of Cardiology, Eberhard-Karls-Universität Tübingen, Tübingen, Germany; Munich University Clinic, Ludwig-Maximilians University, Munich, Germany and DZHK (German Centre for Cardiovascular Research). Electronic address: bauer@thebiosignals.org.
authors.forename: Axel
authors.initials: A
authors.lastname: Bauer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000401:mortality*; D001342:Autonomic Nervous System Diseases / Q000175:diagnosis* / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009026:Mortality / Q000639:trends; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index
keywords: Aortic valve stenosis; Cardiac autonomic function; Deceleration capacity; Heart rate turbulence; Risk prediction