title: Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Strain in Patients With Significant Aortic Stenosis.
abstract: BACKGROUND
  In aortic stenosis (AS), symptoms and left ventricular (LV) dysfunction represent a later disease state, and objective parameters that identify incipient LV dysfunction are needed. We sought to determine prognostic utility of brain natriuretic peptide (BNP) and left ventricular global longitudinal strain (LV-GLS) in patients with aortic valve area <1.3 cm(2).
  
  
  RESULTS
  Five-hundred and thirty-one patients between January 2007 and December 2008 with aortic valve area <1.3 cm(2) (86% with aortic valve area ≤1.1 cm(2)) and left ventricular ejection fraction ≥50% who had BNP drawn ≤90 days from initial echo were included. Society of Thoracic Surgeons (STS) score and mortality were recorded. Mean STS score, glomerular filtration rate, and median BNP were 11±5, 73±35 mL/min per 1.73 m , and 141 (60-313) pg/mL, respectively; 78% were in New York Heart Association class ≥II. Mean LV-stroke volume index (LV-SVI) and LV-GLS were 39±10 mL/m(2) and -13.9±3%. At 4.7±2 years, 405 patients (76%) underwent aortic valve replacement; 161 died (30%). On multivariable survival analysis, age (hazard ratio [HR] 1.46), New York Heart Association class (HR 1.27), coronary artery disease (HR 1.72), decreasing glomerular filtration rate (HR 1.15), increasing BNP (HR 1.16), worsening LV-GLS (HR 1.13) and aortic valve replacement (time dependent) (HR 0.34) predicted survival (all P<0.01). For mortality, the c-statistic incrementally increased as follows (all P<0.01): STS score (0.60 [0.58-0.64]), STS score+BNP (0.67 [0.62-0.70]), and STS score+BNP+LV-GLS (0.74 [0.68-0.78]).
  
  
  CONCLUSIONS
  In normal LVEF patients with significant aortic stenosis, BNP and LV-GLS provide incremental (additive not duplicative) prognostic information over established predictors, suggesting that both play a synergistic role in defining outcomes.
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Andrew
authors.initials: A
authors.lastname: Goodman
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Kenya
authors.initials: K
authors.lastname: Kusunose
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popovic
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Roosha
authors.initials: R
authors.lastname: Parikh
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Tyler
authors.initials: T
authors.lastname: Barr
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: L Leonardo
authors.initials: LL
authors.lastname: Rodriguez
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
authors.affiliation: Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.G., K.K., Z.B.P., R.P., T.B., J.F.S., L.R., L.G.S., B.P.G., M.Y.D.).
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000097:blood / Q000150:complications* / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013314:Stress, Mechanical; D013318:Stroke Volume; D015854:Up-Regulation; D018487:Ventricular Dysfunction, Left / Q000097:blood / Q000175:diagnosis* / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D016277:Ventricular Function, Left
chemical_list: D015415:Biomarkers; D020097:Natriuretic Peptide, Brain
keywords: aortic stenosis; brain natriuretic peptide; global longitudinal strain