NPs can be used To detect subset of asymptomatic with subtle LV dysfunction for further evaluation and earlier referral for intervention and its correlation with echocardiographic finding.

Each patient included in the study will undergo:

1. History taking:

   Analysis of patient symptoms and signs (dyspnea , orthopnea , Paroxysmal nocturnal dyspnea, lower limb edema , tachypalpitations,…etc )

2. Clinical examination:

   • Detecion of each patient body weight , height , calculation of BMI.
   • General examination for detection of signs of Heart failure (raised JVP , lower limb edema, ..etc)
   • Examination to respiratory system
   • Auscultation of the heart for detection of valvular affection before echocardiography

Invesigations:

Laboratory investigations:

Urea and creatinine . b) ECG : for exclusion of atrial fibrillation and other arrythmias. 2D Transthorathic Echocardiography (TTE) Evaluation of valve morphology and thickness , gradients and valve area , regurgitant lesions and its severity.

Evaluation of internal cardiac dimensions and function. 5- Natriuretic peptides: as a useful screening tool to differentiate symptomatic and asymptomatic patients.

Inclusion Criteria:

• All patients echocardiographically diagnosed with significant valve lesions. Rheumatic Heart disease with significant but asymptomatic valvular Heart Disease especially (Mitral valve disease )(MS and MR) Gender: male & female

Exclusion Criteria:

• Cases with increased level of BNP as in :

Renal impairment Advanced age and obesity Atrial fibrillation and acute coronary syndromes Prior lung diseases and acute illness

the study will include consecutive eligible patients recruited in assiut university hospital