HEART failure with preserved ejection fraction (HFpEF) is present in 74% of patients with severe isolated secondary tricuspid regurgitation (TR), but had been previously identified in only 35%, according to recent research. Noninvasive echocardiographic measures of diastolic dysfunction (DD), as defined by current guidelines, failed to detect HFpEF in 60% of cases, highlighting the limitations of existing noninvasive diagnostics in this population.
The study aimed to assess the prevalence of HFpEF and precapillary pulmonary hypertension (PH) among patients with severe isolated TR and to evaluate how well noninvasive measures could detect HFpEF. Patients were retrospectively identified from those undergoing exercise right heart catheterisation (RHC) at the Mayo Clinic from February 2006 to June 2023. Eligible participants were adults with severe isolated TR but without significant left-sided heart disease, left ventricular ejection fraction (EF) below 50%, or other specific cardiac conditions. Diastolic dysfunction was defined by abnormal diastolic parameters on echocardiography, with HFpEF diagnosis established by elevated pulmonary arterial wedge pressure (PAWP) at rest, with feet up, or during exercise. Among the 54 patients studied, 63% were female, and the mean age was 70.8 years. In most cases (67%), RHC was requested for TR evaluation before potential intervention, and in 24%, for assessing pulmonary hypertension. Results showed that 74% of patients had HFpEF, though only 35% had been recognized with HFpEF before the invasive testing. Of those without HFpEF, 71% had precapillary PH. Standard guideline-based DD criteria missed HFpEF in 60% of cases, whereas advanced echocardiographic measures of left atrial emptying fraction (AUC = 0.90) and strain (AUC = 0.91) demonstrated better discrimination for HFpEF detection.
These findings underscore the high prevalence of undiagnosed HFpEF in patients with isolated severe TR, suggesting that HFpEF should be routinely considered in these patients. In clinical practice, reliance solely on guideline-defined DD criteria may result in missed HFpEF diagnoses, emphasizing the need for enhanced noninvasive diagnostics such as left atrial functional assessment. Given that HFpEF and precapillary PH require specific therapeutic approaches beyond those for TR, clinicians should maintain a low threshold for referring patients with severe isolated TR for invasive testing. Enhanced detection may enable timely initiation of HFpEF-specific treatments, potentially improving outcomes for this patient population.
Reference
Naser JA et al. Prevalence of HFpEF in isolated severe secondary tricuspid regurgitation. JAMA Cardiol. 2024;DOI:10.1001/jamacardio.2024.3767.
