A new study published in JACC has evaluated the prevalence and prognostic significance of secondary tricuspid regurgitation (STR) across the spectrum of heart failure with preserved ejection fraction (HFpEF), finding that its presence is strongly associated with pulmonary vascular disease (PVD) and that different mechanisms of STR carry distinct prognoses.¹˒²
This observational study analysed data from 1,091 patients referred for invasive haemodynamic assessment. Of these, 669 patients (median age 65 years, 60.3% women) were diagnosed with HFpEF. Researchers compared cardiac structure, function, haemodynamics, and clinical outcomes among HFpEF phenotypes, which were categorised based on the presence of PVD (pulmonary vascular resistance >2 WU) and whether filling pressures were elevated at rest or only during provocation (leg-elevation or exercise). Patients were also categorised according to the presence of atrial (A-STR) or ventricular (V-STR) mechanisms of regurgitation.
Overall, moderate or severe STR was present in 17.4% of patients. The prevalence increased significantly with the presence and severity of PVD and resting congestion, rising from 6.7% in patients with exercise-only HFpEF without PVD to 33.7% in those with resting HFpEF and PVD. Notably, moderate or severe STR was still more common in patients with exercise-only HFpEF compared to those with noncardiac dyspnoea (11.7% vs 6.5%; p=0.047).
Ventricular STR was the more common phenotype, accounting for 69% of cases. These patients displayed greater atrial remodelling compared with A-STR patients, despite having a similar prevalence of atrial fibrillation.
Regarding clinical outcomes, V-STR was independently associated with a composite of death or heart failure (HF) hospitalisation (multivariable HR: 1.70; 95% CI: 1.10–2.65), as well as with each endpoint individually. In contrast, A-STR was associated with an increased risk of HF hospitalisations only (multivariable Fine-Gray HR: 2.21; 95% CI: 1.12–4.37).
The findings highlight that while STR in HFpEF is linked to advanced disease stages involving PVD, it is also prevalent in earlier stages, such as exercise-induced HFpEF, underscoring the importance of exercise haemodynamics in diagnosis. The study differentiates the prognostic impact of STR mechanisms, with the authors concluding that “V-STR conferred excess mortality and HF hospitalisations, but A-STR conferred only excess HF hospitalisations.”¹ The data also suggest that even in V-STR, a substantial atrial myopathy may contribute, indicating a potential mixed mechanism.
References
1. Naser JA, Harada T, Tada A, et al. Tricuspid regurgitation across the spectrum of heart failure with preserved ejection fraction. J Am Coll Cardiol. 2025;86(24):2495–2508. https://doi.org/10.1016/j.jacc.2025.09.007
2. Hahn RT, Lindenfeld J, Bohm M, et al. Tricuspid regurgitation in patients with heart failure and preserved ejection fraction: JACC state-of-the-art review. J Am Coll Cardiol. 2024;84(2):195–212. https://doi.org/10.1016/j.jacc.2024.04.047
Disclaimer: The information presented in this article is for educational purposes only. Any quotes included reflect the opinions of the individual quoted, and do not necessarily reflect the views of the publisher. The publisher does not guarantee the accuracy or completeness of the content and accepts no responsibility for any errors, or any consequences arising from its use.