Author + information
- Received August 26, 2019
- Revision received December 2, 2019
- Accepted January 24, 2020
- Published online August 3, 2020.
- Diab Mutlak, MD,
- Jawad Khalil, MD,
- Jonathan Lessick, MD, DSc,
- Izhak Kehat, MD, PhD,
- Yoram Agmon, MD and
- Doron Aronson, MD∗ ()
- Department of Cardiology, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion Medical School, Haifa, Israel
- ↵∗Address for correspondence:
Dr. Doron Aronson, Department of Cardiology, Rambam Medical Center, POB 9602, Haifa 31096, Israel.
Objectives The objective of this study was to determine risk factors for progression to hemodynamically significant tricuspid regurgitation (TR) and the population burden attributable to these risk factors.
Background Few data are available with regard to risk factors associated with the development of hemodynamically significant functional TR.
Methods A total of 1,552 subjects were studied beginning with an index echocardiogram demonstrating trivial or mild TR. Risk factors for progression to moderate or severe TR were determined by using logistic regression and classification trees. Population attributable fractions were calculated for each risk factor.
Results During a median follow-up time of 38 (interquartile range [IQR]: 26 to 63) months, 292 patients (18.8%) developed moderate/severe TR. Independent predictors of TR progression were age, female sex, heart failure, pacemaker electrode, atrial fibrillation (AF), and indicators of left heart disease, including left atrial (LA) enlargement, elevated pulmonary artery pressure (PAP), and left-sided valvular disease. Classification and regression tree analysis demonstrated that the strongest predictors of TR progression were PAP of ≥36 mm Hg, LA enlargement, age ≥60 years, and AF. In the absence of these 4 risk factors, progression to moderate or severe TR occurred in ∼3% of patients. Age (28.4%) and PAP (20.5%) carried the highest population-attributable fractions for TR progression. In patients with TR progression, there was a marked concomitant increase of incident cases of elevated PAP (40%); mitral and aortic valve intervention (12%); reductions in left ventricular ejection fraction (19%), and new AF (32%) (all p < 0.01).
Conclusions TR progression is determined mainly by markers of increased left-sided filling pressures (PAP and LA enlargement), AF, and age. At the population level, age and PAP are the most important contributors to the burden of significant TR. TR progression entails a marked parallel increase in the severity of left-sided heart disease.
- disease progression
- natural history
- population-attributable fraction
- risk factors
- tricuspid regurgitation
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.
- Received August 26, 2019.
- Revision received December 2, 2019.
- Accepted January 24, 2020.
- 2020 American College of Cardiology Foundation
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