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Natriuretic peptides for risk stratification of patients with valvular aortic stenosis.

Risk stratification of patients with aortic stenosis (AS) is important especially in high-risk asymptomatic patients, patients with atypical symptoms, and those with symptoms but with a high surgical or procedural risk. Current American College of Cardiology/American Heart Association guidelines for indications to proceed with aortic valve replacement (AVR) for AS are the presence of symptoms because of AS, a left ventricular (LV) ejection fraction of <50%, and the need for concomitant valve repair or coronary artery bypass grafting.1 However, reliance on patient-reported symptoms can be misleading. Patients may knowingly or unknowingly adjust their lifestyles to avoid exacerbating symptoms or may not notify their physicians at the onset of symptoms. It may also be difficult to distinguish whether symptoms are caused by AS when patients have other comorbidities, such as lung disease or deconditioning, the latter being a major concern in elderly patients. Furthermore, the requisite serial follow-up at 6- to 12-month intervals1 to ensure that patients are clinically and echocardiographically stable may be difficult for elderly, infirm, or economically disadvantaged patients. Surgical delays because of unrecognized symptoms from AS or infrequent follow-up increase the risk of lethal complications and operative risk.2 In the past few years, 2 factors have been emerged which may change the current guideline-driven approach to AVR: (1) the advent of transcatheter AVR (TAVR) and (2) the recognition that patients with low-gradient AS also benefit from AVR.1 Although the procedural risk may be lower in TAVR versus surgical AVR (SAVR), both carry potential complications, including those associated with prosthetic valves. Therefore, optimal timing for the referral to AVR remains important and any development that enhances risk stratification of patients is important for the management of asymptomatic and symptomatic patients with severe AS.2,3

As shown in Figure 1, natriuretic peptides, …