Association of Diuretic Dosage With Outcomes in Patients With Hemodynamically Significant Isolated Tricuspid Valve...

Tricuspid valve surgery is recommended for severe isolated tricuspid regurgitation (TR) if symptoms persist despite optimal medical therapy. The definition of optimal therapy for TR is unclear beyond managing underlying conditions. Diuretics are the primary treatment for volume retention in TR, but it is unknown whether a "safe diuretic dose" exists for conservative management. We sought to evaluate the association between diuretic dose and outcomes.

Adult patients with ≥moderate-severe isolated TR were retrospectively identified from echocardiographic reports. Clinical and echocardiographic data were extracted from electronic medical records and manually reviewed. The primary end point was all-cause mortality. Loop diuretic doses were converted to furosemide equivalent and categorized into 4 groups: <40 mg, 40 to 79 mg, 80 to 159 mg, and ≥160 mg daily.

Of 1302 patients (age 72±13 years, 60% female), 565 (43%) had moderate-severe TR and 737 (57%) had severe TR. Median follow-up was 8.7 (1.4, 14.0) years. Comorbidities increased with higher diuretic doses. A linear relationship between diuretic dose and mortality was observed in spline-curve analysis. Hazard ratios (and CIs) for mortality adjusted for age, sex, coronary disease, chronic kidney disease, mild pulmonary hypertension, and New York Heart Association III/IV symptoms were 1.21 (0.96-1.53) (P=0.12) for <40 mg, 1.50 (1.23-1.82) (P <0.001) for 40 to 79 mg, 1.86 (1.46-2.37) (P <0.001) for 80 to 159 mg, and 2.90 (2.18-3.88) (P <0.001) for ≥160 mg furosemide equivalent. Any diuretic dose was associated with significant symptoms (New York Heart Association III-IV), with more patients experiencing symptoms at higher doses.

A daily loop diuretic dose ≥40 mg furosemide equivalent is associated with increased mortality and greater symptom severity in patients with TR.