Independent and incremental prognostic value of semiquantitative measures of tricuspid regurgitation severity in heart failure with preserved ejection fraction

Abstract

Aims This study sought to determine the independent and incremental prognostic value of semiquantitative measures of tricuspid regurgitation (TR) severity over right heart remodelling and pulmonary hypertension (PH) in heart failure with preserved ejection fraction (HFpEF). Methods and results Echocardiography was performed on 311 HFpEF patients. TR severity was defined by the semiquantitative measures [i.e. vena contracta width (VCW) and jet area] and by the guideline-based integrated qualitative approach (absent, mild, moderate, or severe). All-cause mortality or heart failure hospitalization occurred in 101 patients over a 2.1-year median follow-up. There was a continuous association between TR severity and the composite outcome with a hazard ratio (HR) of 1.17 per 1 mm increase of VCW [95% confidence interval (CI) 1.08–1.26, P < 0.0001]. Compared with patients with the lowest VCW category (≤1 mm), RV-adjusted HRs for the outcome were 1.99 (95% CI 1.05–3.77), 2.63 (95% CI 1.16–5.95), and 5.00 (95% CI 1.60–15.7) for 1–3, 3–7, and ≥7 mm VCW categories, respectively. TR severity as defined by the guideline-based approach showed a similarly graded association, but it was no longer significant in models including PH. In contrast, VCW remained independently and incrementally associated with the outcome after adjusting for established prognostic factors, as well as RV diameter and PH (fully adjusted HR 1.14 per 1 mm, 95% CI 1.02–1.27, P = 0.02; χ2 58.8 vs. 51.5, P = 0.03). Conclusion The current data highlight the potential value of the semiquantitative measures of TR severity for the risk stratification in patients with HFpEF.

Visual echocardiographic scoring system of the left ventricular filling pressure and outcomes of heart failure with preserved ejection fraction

“…This was a retrospective, two-centre, observational study that assessed the VMT score and clinical outcomes in patients with HFpEF. Some participant data from this study have been recently published; 12 however, they were not regarding VMT scoring. Any patients included in the former invasive-echocardiographic study 11 were not included in the present investigation.…”

Right atrial pressure represents cumulative cardiac burden in heart failure with preserved ejection fraction

“…In this retrospective observational study, we evaluated the association between echocardiographic markers of RAP and clinical outcomes in stable patients with HFpEF. Some participant data from this study have been previously published, 16,18,21,22 but not as it relates to the prognostic value of eRAP. We identified patients who were admitted to either Gunma University Hospital in Maebashi, Japan, between January 2014 and June 2019 or Hokkaido University Hospital in Sapporo, Japan, between January 2014 and December 2018.…”

“…29 TR is also common in HFpEF, causing elevations in RAP through RA volume overload. 16,30 In both circumstances, RA remodelling may progress and RA compliance may decrease, leading to a further increase in RAP. AF may compromise RA compliance as well by inducing myocardial fibrosis and remodelling.…”

“…These may include diuretics to reduce volume overload and PA pressures, interventions to reduce tricuspid insufficiency, and maintenance or restoration of AF. 16,38 Sodium-glucose co-transporter 2 inhibitors may be effective for reducing volume overload and RAP. 39 Further studies are warranted to determine how to optimally treat RA hypertension in patients with HFpEF.…”

“…[12][13][14] Elevated right heart filling pressure in HFpEF may be mediated by pulmonary hypertension (PH) due to high LV filling pressures, right ventricular (RV) dysfunction, worsening tricuspid insufficiency, right atrial (RA) dysfunction, and increasing burden of atrial fibrillation (AF), each of which is associated with adverse outcomes. 12,13,[15][16][17][18] Hence, we speculated that right-sided filling pressure may represent the cumulative burden of these cardiac abnormalities and may provide valuable information for risk stratification in HFpEF. 19 Right heart filling pressure can be readily estimated using echocardiography based on inferior vena cava (IVC) morphology, 20 but few studies have reported the prognostic value of estimated right atrial pressure (eRAP) in patients with HFpEF.…”