European Heart Journal Advance Access published online on January 17, 2008
European Heart Journal, doi:10.1093/eurheartj/ehm553
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Elevated B-type natriuretic peptide despite normal left ventricular function on rest and exercise stress echocardiography in mitral regurgitation
1 Department of Cardiology, Middlemore Hospital, Hospital Road, Private Bag 93311, Otahuhu, Auckland, New Zealand
2 Department of Medicine, The University of Auckland, Auckland, New Zealand
3 Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
Received 24 June 2007; revised 19 October 2007; accepted 25 October 2007.
* Corresponding author. Tel: +64 9 2760000 ext. 8061, Fax: +64 9 2709746, Email: andrewkerr{at}middlemore.co.nz
See page 29 for the editorial comment on this article (doi:10.1093/eurheartj/ehm593)
Aims: To determine whether elevated B-type natriuretic peptide (BNP) predicts left ventricular (LV) contractile dysfunction on exercise stress echocardiography in patients with severe mitral regurgitation (MR).
Methods and results: Thirty three patients with moderate-to-severe or severe MR, a LV ejection fraction 
60% and New York Heart Association Class I or II symptoms, and 12 controls underwent resting and exercise stress echocardiography. In 20 MR patients, BNP was within the normal range (mean ± SD, 7.7 ± 2.7 pmol/L), and in 13 MR patients, BNP was >12 pmol/L (19.6 ± 7.6 pmol/L). LV end-systolic volume index after exercise was lower in controls than patients with MR (P < 0.0001), but similar in MR patients with normal and elevated BNP, respectively (controls 8.5 ± 3.9, MR 20 ± 7 vs. 20 ± 9 cm2/m2, P > 0.05). However, pulmonary artery systolic pressure (PAP) after exercise was higher in MR with high BNP (70 ± 20 vs. 48 ± 11 mmHg, <0.0001) and controls (38±11 mmHg). A two-fold increase in plasma BNP was associated with an average increase in resting PAP of 7.6 (95% CI 2.9, 12.2) mmHg, an increase in post-exercise PAP of 14.4 (95% CI 9.0, 19.9) mmHg and increase in left atrial area index of 2.1 (95% CI 0.5, 3.8) cm2/m2. However, there was no significant association between the plasma level of BNP and any rest or post-exercise measure of LV systolic function (r < 0.25, P > 0.05 for all).
Conclusion: The plasma level of BNP may be within the normal range in patients with moderate-to-severe or severe MR despite significant increases in LV end-systolic volume. Increase in BNP is associated with pulmonary artery hypertension on exercise and left atrial enlargement even when LV systolic function on exercise stress echocardiography is normal.
Key Words: Mitral regurgitation • B-type natriuretic peptide • Exercise stress echocardiography
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