The prevalence and impact of changes in the severity of secondary TR during hospitalization in acute heart failure

Abstract Background Secondary tricuspid regurgitation (TR) is a prevalent entity in patients hospitalized for acute heart failure (AHF), and concomitant moderate or severe TR at admission has been demonstrated to be associated with a poor prognosis. However, no study has described the trajectories of the severity of secondary TR during admission, and the prognostic implications of changes in the severity of secondary TR. Purpose This study aimed to investigate the dynamism of secondary TR observed during hospitalization due to worsening heart failure, and its prognostic impact in patients with AHF. Methods A post-hoc analysis of 1,061 consecutive patients hospitalized with AHF was performed, enrolled in the prospective, multicenter Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF). Patients included in the study underwent a comprehensive echocardiographic examination within 24 hours of admission and again prior to discharge. Patients were divided into four groups based on the TR severity at admission and discharge: none to mild TR at both admission and discharge (no/no group), moderate to severe TR at admission but improved to none to mild TR at discharge (resolution group), none to mild TR at admission but moderate to severe TR at discharge (worsening group), and moderate to severe TR at both admission and discharge (persistent group). The primary endpoint was the composite of 1-year all-cause mortality and HF re-hospitalization after discharge. Results The no/no, resolution, worsening, and persistent groups included 479 (45%), 275 (26%), 85 (8%), and 222 patients (21%), respectively. The no/no group and the resolution group had significantly lower tricuspid regurgitant pressure gradients prior to discharge compared to the worsening and persistent groups (P<0.001). Also, right ventricular dysfunction evaluated at discharge, defined by tricuspid annular plane systolic excursion <17 mm, was more prevalent in the worsening (65.7%) and persistent groups (66.4%) compared to the no/no (43.7%) and resolution (53.2%) groups (P<0.001). Compared to the no/no group, the worsening and persistent groups, but not the resolution group, were associated with a higher incidence of the primary endpoint (Log-rank: P<0.001). This association remained significant in an adjusted Cox regression analysis, with the worsening group (hazard ratio: 1.48, 95% confidence interval [CI]: 1.01–2.20) and persistent group (hazard ratio: 1.35, 95% CI: 1.01–1.83) independently associated with the primary endpoint, but not the resolution group (hazard ratio: 1.10, 95% CI: 0.81–1.49). Conclusions In patients hospitalized for AHF, the severity of secondary TR is dynamic, and changes in the severity of TR are significantly associated with prognosis. Our study results underscore the importance of repetitive evaluation of TR in hospitalized patients with AHF.