Aims Serum biomarkers have a potential role in the risk stratification of patients with heart valve disease and may help determine the optimal timing of intervention. Much of the published literature relates to biomarker sampling in a resting state, but the relationship of exercise biomarkers is less well described. We performed a systematic review to examine the significance of exercise natriuretic peptides on echocardiographic variables and cardiovascular events, in valvular heart disease. Methods A search for studies that assessed exercise biomarkers in patients with moderate to severe valve lesions was performed. We examined the relationship between rest and exercise BNP and also the endpoints of symptoms, haemodynamic or echocardiographic variables and clinical outcomes. Results 11 prospective studies were identified (844 participants). 61% were male and the mean age was 55.2 ± 9.6 years. The majority of the blood samples were taken at baseline and within 3 minutes of stopping exercise. There was a significant increase in exercise BNP compared with rest, in patients with aortic stenosis, mitral regurgitation and mitral stenosis. Elevated exercise BNP levels correlated with mean gradient and left atrial area, and there was a relationship between a higher exercise BNP and a blunted blood pressure response, in aortic stenosis. Furthermore, exercise BNP was independently associated with cardiac events, over and above resting values, in patients with mitral regurgitation and aortic stenosis. Conclusions The results suggesting that exercise natriuretic peptide levels may have additive prognostic importance over resting levels, as well as demographic and echocardiographic data.

Aims The extent to which augmentation of heart function mirrors the increased metabolic demands of the peripheral musculature is not well characterised. The details of ventricular augmentation may provide insight into determinants of cardiac efficiency for optimal exercise performance. The aims were to establish how much of the variability in exercise performance could be explained by myocardial recruitment, and which parameter of systolic function was most closely related to exercise performance. Methods and results Untrained volunteers were recruited prior to training for the London Marathon. All performed a cardiopulmonary exercise test combined with stress echocardiography. Systolic and diastolic longitudinal velocities (S’ and E’), ejection fraction (LVEF), stroke volume (SV) and strain were obtained throughout exercise. Continuous S’ showed a strong correlation with absolute VO2 (rho=0.83;p<0.0001). Only SV and S’ were predictive of VO2peak. LVEF and E’ as well as both global longitudinal and circumferential strain showed no correlation. The systolic efficiency slope (SES) was calculated by determining the individual regression lines for VO2 and S’. A moderate relationship between the SES and VO2peak was observed for both septal S’; r=0.57;p<0.001 and lateral S’, r=0.53;p<0.001). Conclusion A detailed description of myocardial function is described; linear for S’ and E’ and a plateau for EF and GLS. S’ during exercise is a better predictor of exercise performance than LVEF, SV or GLS. The SES slope was able to predict VO2peak suggesting the process driving systolic velocity and its augmentation is a key determinant of exercise ability.