Background-The onset of symptoms is a critical point in the natural history of aortic stenosis and the cardinal indication for valve replacement. This study assessed the associations between natriuretic peptide levels, disease severity, and cardiac symptoms in aortic stenosis. Methods and Results-Seventy-four patients with isolated aortic stenosis underwent independent assessment of symptoms, transthoracic echocardiography, and measurement of plasma levels of atrial natriuretic peptide, brain natriuretic peptide (BNP), and N-BNP. Natriuretic peptide levels were also measured in 100 clinically normal control subjects. The aortic valve area was smaller in symptomatic patients (nϭ45) than in asymptomatic patients (nϭ29; mean, 0.71Ϯ0.23 cm 2 and 0.99Ϯ0.31 cm 2 , respectively; PϽ0.0001). Plasma natriuretic peptide levels were higher in symptomatic patients than in asymptomatic patients (for N-BNP: median, 112 versus 33 pmol/L; interquartile range, 70 to 193 versus 16 to 58 pmol/L, respectively; Pϭ0.0002). After adjustment for age, sex, serum creatinine, aortic valve area, and left ventricular ejection fraction, N-BNP levels were 1.74 times higher (95% confidence interval, 1.12 to 2.69) for symptomatic than asymptomatic patients with aortic stenosis (Pϭ0.014). Natriuretic peptide levels increased with the New York Heart Association class (for N-BNP median values were 13, 34, 105, and 202 pmol/L for normal control subjects, class I, class II, and class III/IV patients, respectively; interquartile ranges for the same patients were 8 to 21, 16 to 58, 57 to 159, and 87 to 394 pmol/L; PϽ0.0001). Similar associations were observed for BNP and atrial natriuretic peptide. Conclusions-Plasma natriuretic peptide levels are elevated in symptomatic patients with aortic stenosis. Measurement of natriuretic peptides may complement clinical and echocardiographic evaluation of patients with aortic stenosis.

Plasma natriuretic peptides levels increase with the severity of MR and are higher in symptomatic compared to asymptomatic patients, even when LV EF is normal.

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Background-Levosimendan is a calcium-sensitizing agent and an inodilator under current investigation in the treatment of decompensated heart failure. The effects of intravenous levosimendan on the human coronary vasculature, together with myocardial wall stress and oxygen uptake, have not been adequately studied. Methods and Results-Ten adult patients underwent right-and left-heart catheterization. Baseline coronary blood flow was determined with quantitative coronary angiography and an intracoronary Doppler-tipped guidewire. Myocardial oxygen uptake was measured with a coronary sinus catheter. Echocardiography was performed before and 30 minutes after an intravenous infusion of levosimendan (24-g/kg bolus over 10 minutes) was begun.

ContextThe third (S 3 ) and fourth (S 4 ) heart sounds detected by phonocardiography are considered to represent the criterion standards of the gallop sounds, but their test characteristics have not been explored.Objective To determine the diagnostic test characteristics of the S 3 and S 4 for prediction of left ventricular dysfunction using a computerized heart sound detection algorithm.Design, Setting, and Participants Prospective study of 90 adult patients undergoing elective left-sided heart catheterization at a single US teaching hospital between August 2003 and June 2004. The mean age was 62 (SD, 13) years (range, 24-90 years) and 61 (68%) were male. Within a 4-hour period, participants underwent computerized heart sound phonocardiographic analysis, cardiac catheterization, transthoracic echocardiography, and blood sampling for assessment of an S 3 /S 4 , left ventricular end-diastolic pressure (LVEDP), left ventricular ejection fraction (LVEF), and B-type natriuretic peptide (BNP), respectively.Main Outcome Measures Diagnostic test characteristics of the computerized phonocardiographic S 3 and S 4 using markers of left ventricular function as criterion standards.Results Mean (SD) LVEDP was significantly elevated (18.4 [6.9] mm Hg vs 12.1 [7.3] mm Hg; PϽ.001), mean (SD) LVEF was reduced (49.4% [20.2%] vs 63.6% [14.8%]; PϽ.001), and median (interquartile range) BNP was elevated (330 [98-1155] pg/mL vs 86 pg/mL; PϽ.001) in those with an S 3 , S 4 , or both compared with patients without a diastolic heart sound. The sensitivities of these heart sounds to detect an elevated LVEDP, reduced LVEF, or elevated BNP were 41%, 52%, and 32% for an S 3 , and 46%, 43%, and 40% for an S 4 , respectively. For abnormal levels of the same markers of ventricular function, the specificities of the S 3 were 92%, 87%, and 92%, while the specificities of the S 4 were 80%, 72%, and 78%, respectively.Conclusions Neither the phonocardiographic S 3 nor the S 4 is a sensitive marker of left ventricular dysfunction. The phonocardiographic S 3 is specific for left ventricular dysfunction and appears to be superior to the moderate specificity of the phonocardiographic S 4 .