Tricuspid Regurgitation Across the Spectrum of Heart Failure With Preserved Ejection Fraction

Secondary tricuspid regurgitation (STR) in heart failure with preserved ejection fraction (HFpEF) is linked to more advanced stages with pulmonary vascular disease (PVD), but it may also develop at earlier stages of HFpEF, such as those with isolated exercise-induced congestion.

This study sought to evaluate the prevalence, distribution, and prognostic significance of STR mechanisms across the spectrum of HFpEF.

Cardiac structure, function, hemodynamics, and clinical outcomes were compared among patients with HFpEF phenotypes categorized according to the presence of PVD (pulmonary vascular resistance >2 WU), and elevation in filling pressure at rest vs provocation (leg-elevation or exercise), as well as according to the presence of atrial or ventricular STR (A-STR, V-STR).

Of 1,091 patients (median age 65 years, 60.3% women), 669 (61.3%) had HFpEF (20.2% exercise HFpEF - PVD, 38.6% rest HFpEF - PVD, 15.5% exercise HFpEF + PVD, 25.7% rest HFpEF + PVD). Moderate or severe STR was present in 17.4% overall, but increased with PVD (6.7%, 11.6%, 18.3%, and 33.7%, respectively), although moderate or severe STR was still more common in exercise-only HFpEF vs noncardiac dyspnea patients (11.7% vs 6.5%; P = 0.047). Most STR (69%) fulfilled criteria for V-STR, but those individuals had similar atrial fibrillation prevalence and greater atrial remodeling compared with A-STR. V-STR was independently associated with composite of death or heart failure (HF) hospitalization (multivariable HR: 1.70; 95% CI: 1.10-2.65) as well as death and HF hospitalizations each alone, whereas A-STR was associated with increased risk of HF hospitalizations (multivariable Fine-Gray HR: 2.21; 95% CI: 1.12-4.37).

STR in HFpEF is associated with PVD and less strongly with higher resting filling pressure. Although V-STR is the more common phenotype of STR in HFpEF, these patients also have substantial atrial myopathy, suggesting a mixed mechanism. TR was more prevalent in exercise HFpEF and exercise pulmonary hypertension than with noncardiac dyspnea; with none in the latter group having moderate-severe or severe TR, highlighting the importance of exercise hemodynamics. V-STR conferred excess mortality and HF hospitalizations, but A-STR conferred only excess HF hospitalizations.