medwireNews: Heart failure with preserved ejection fraction (HFpEF) may be present in up to three quarters of patients with severe secondary tricuspid regurgitation (STR) of undefined etiology (isolated) but it is being overlooked, suggest researchers.
In their retrospective single-center study, the team found that 74% of 54 adults with severe isolated STR referred for exercise right-heart catheterization (RHC) had HFpEF, but it was recognized in only 35% prior to this invasive test.
Moreover, resting diastolic dysfunction according to current guidelines was “insufficiently sensitive in these patients,” missing 60% of HFpEF cases, Barry Borlaug, (Mayo Clinic College of Medicine, Rochester, Minnesota, USA) and colleagues report in JAMA Cardiology.
The study participants (mean age 70.8 years, 63% women) were referred for RHC between 2006 and 2023 for evaluation of tricuspid regurgitation (TR) before potential intervention in 67%, evaluation of pulmonary hypertension (PH) in 24%, or confirmation of HFpEF in 9%. HFpEF was defined by a pulmonary arterial wedge pressure of at least 15 mmHg at rest, at least 19 mmHg with feet up, or at least 25 mmHg during exercise.
On RHC, 40 patients met the criteria for HFpEF, and precapillary PH was diagnosed in 10 (71%) of the remaining 14 patients. Only 48% of the HFpEF cases identified at catheterization had been previously diagnosed or recognized, and diastolic dysfunction on echocardiography failed to identify HFpEF in 24 of the 40 patients who were subsequently diagnosed.
“This finding is critical, especially as tricuspid transcatheter therapy becomes increasingly used,” comment Borlaug et al. They continue that the study “reinforces the importance of identifying patients who can benefit from the available HFpEF- and PH-specific therapy concurrently with or prior to consideration of TR intervention.”
Patients with HFpEF tended to be older than those without HFpEF (mean 74.0 vs 61.6 years) and have more comorbid conditions, including atrial fibrillation (85%) and chronic obstructive pulmonary disease (20%).
The finding that diastolic dysfunction was absent in more than half of HFpEF cases indicates a need for other noninvasive diagnostic tools, say the investigators. Noninvasive measures of left atrial function showed better discrimination and higher sensitivity for HFpEF, with an area under the receiver operating characteristic curve of 0.90 for left atrial emptying fraction, 0.91 for left atrial strain, and 0.92 for left atrial compliance.
However, Borlaug et al say that “future studies are needed to confirm their role” and in the meantime “HFpEF should be suspected in patients with apparently isolated secondary TR, and a low threshold to refer for invasive testing should be considered.”
In an accompanying editor’s note, Clyde Yancy (Feinberg School of Medicine, Chicago, Illinois, USA) and others say that, with further corroboration, “it may be time for a paradigm shift that includes HFpEF in the clinical evaluation of secondary severe TR,” but recommend “a paradigm return in selected cases to invasive assessment,” if there is any doubt.
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JAMA Cardiol 2024; doi:10.1001/jamacardio.2024.3767
JAMA Cardiol 2024; doi:10.1001/jamacardio.2024.3764
