Prevalence of HFpEF in Isolated Severe Secondary Tricuspid Regurgitation.

IF 14.8 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS
Jwan A Naser, Tomonari Harada, Yogesh N Reddy, Sorin V Pislaru, Hector I Michelena, Christopher G Scott, Austin M Kennedy, Patricia A Pellikka, Vuyisile T Nkomo, Mackram F Eleid, Barry A Borlaug
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引用次数: 0

Abstract

Importance: Secondary tricuspid regurgitation (STR) is observed in multiple cardiac and pulmonary diseases. Heart failure with preserved ejection fraction (HFpEF) is a common cause of STR that may be overlooked, along with precapillary etiologies of pulmonary hypertension (PH).

Objectives: To investigate the prevalence of HFpEF and precapillary PH in patients with severe STR of undefined etiology (isolated STR) referred for exercise right heart catheterization (RHC), and to evaluate the performance of noninvasive measures to identify HFpEF.

Design, setting, and participants: This retrospective cross-sectional study included consecutive adults with severe STR in the absence of EF less than 50%, hemodynamically significant left-sided valve disease, congenital heart disease, infiltrative or hypertrophic cardiomyopathy, pericardial disease, or prior cardiac procedures who underwent rest-and-exercise RHC between February 2006 and June 2023 at Mayo Clinic and transthoracic echocardiography less than 90 days prior. Diastolic dysfunction (DD) was defined by at least 3 of 4 or 2 of 3 abnormal diastolic parameters (medial e', medial E/e', tricuspid regurgitation [TR] velocity, left atrial volume index). HFpEF was diagnosed when pulmonary arterial wedge pressure was at least 15 mm Hg at rest, at least 19 mm Hg with feet up, or at least 25 mm Hg during exercise. Data analysis was performed from November 2023 to March 2024.

Main outcomes and measures: The prevalence of HFpEF and precapillary PH in severe isolated STR was determined, and performance of noninvasive measures to identify HFpEF was evaluated.

Results: Overall, 54 patients with severe isolated STR (mean [SD] age, 70.8 [12.5] years; 34 [63%] female) were identified. The primary indication for RHC was evaluation of TR prior to potential intervention in 36 patients (67%), evaluation of PH in 13 (24%), and confirmation of HFpEF in 5 (9%). HFpEF was identified in 40 patients (74%) but was recognized prior to RHC in only 19 patients (35%). Of the 14 remaining patients without HFpEF, precapillary PH was diagnosed in 10 (71%). Guideline-defined DD was absent in 24 patients (60%) who were subsequently diagnosed with HFpEF. Left atrial emptying fraction (area under the receiver operating characteristic curve [AUC] = 0.90; 95% CI, 0.82-0.98) and strain (AUC = 0.91; 95% CI, 0.83-0.99) had robust discrimination for HFpEF.

Conclusions and relevance: The findings suggest that HFpEF is underdiagnosed and should be rigorously evaluated for in patients with severe isolated STR, along with precapillary PH, as both have distinct requirements for management. Resting DD based on current guidelines is insufficiently sensitive in these patients, indicating a pressing need for other noninvasive diagnostic tools, such as left atrial function assessment.

孤立性重度继发性三尖瓣反流中高频血流衰竭的患病率
重要性:继发性三尖瓣反流(STR)可见于多种心脏和肺部疾病。射血分数保留型心力衰竭(HFpEF)是导致三尖瓣反流的常见原因,可能会与肺动脉高压(PH)的毛细血管前病因一起被忽视:调查病因不明的严重STR(孤立性STR)患者中HFpEF和毛细血管前PH的患病率,并评估非侵入性措施识别HFpEF的性能:这项回顾性横断面研究纳入了在 2006 年 2 月至 2023 年 6 月期间在梅奥诊所接受静息-运动 RHC 检查,并在检查前 90 天内接受经胸超声心动图检查的连续重度 STR 成人患者,这些患者均无 EF 小于 50%、血流动力学显著左侧瓣膜病、先天性心脏病、浸润性或肥厚性心肌病、心包疾病或既往接受过心脏手术。舒张功能障碍(DD)的定义是舒张参数(内侧e'、内侧E/e'、三尖瓣反流[TR]速度、左心房容积指数)4项中至少3项或3项中至少2项异常。当静息时肺动脉楔压至少为 15 毫米汞柱,抬脚时至少为 19 毫米汞柱,或运动时至少为 25 毫米汞柱时,即可诊断为高频肺功能衰竭。数据分析时间为2023年11月至2024年3月:主要结果:确定了严重孤立性 STR 中 HFpEF 和毛细血管前 PH 的患病率,并评估了识别 HFpEF 的无创措施的性能:结果:总计发现了 54 名重度孤立性 STR 患者(平均 [SD] 年龄 70.8 [12.5] 岁;女性 34 [63%])。36 名患者(67%)RHC 的主要适应症是在潜在干预前评估 TR,13 名患者(24%)评估 PH,5 名患者(9%)确认 HFpEF。有 40 名患者(74%)被确诊为 HFpEF,但只有 19 名患者(35%)在进行 RHC 之前被确诊。在剩下的 14 名没有 HFpEF 的患者中,有 10 人(71%)被诊断为毛细血管前 PH。在随后被诊断为 HFpEF 的 24 名患者(60%)中,没有出现指南定义的 DD。左心房排空分数(接收器操作特征曲线下面积 [AUC] = 0.90;95% CI,0.82-0.98)和应变(AUC = 0.91;95% CI,0.83-0.99)对 HFpEF 有很强的鉴别作用:研究结果表明,HFpEF 的诊断率较低,应严格评估严重孤立 STR 患者和毛细血管前 PH 患者的情况,因为两者都有不同的治疗要求。根据目前的指南,静息 DD 对这些患者的敏感性不足,这表明迫切需要其他无创诊断工具,如左心房功能评估。
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来源期刊
JAMA cardiology
JAMA cardiology Medicine-Cardiology and Cardiovascular Medicine
CiteScore
45.80
自引率
1.70%
发文量
264
期刊介绍: JAMA Cardiology, an international peer-reviewed journal, serves as the premier publication for clinical investigators, clinicians, and trainees in cardiovascular medicine worldwide. As a member of the JAMA Network, it aligns with a consortium of peer-reviewed general medical and specialty publications. Published online weekly, every Wednesday, and in 12 print/online issues annually, JAMA Cardiology attracts over 4.3 million annual article views and downloads. Research articles become freely accessible online 12 months post-publication without any author fees. Moreover, the online version is readily accessible to institutions in developing countries through the World Health Organization's HINARI program. Positioned at the intersection of clinical investigation, actionable clinical science, and clinical practice, JAMA Cardiology prioritizes traditional and evolving cardiovascular medicine, alongside evidence-based health policy. It places particular emphasis on health equity, especially when grounded in original science, as a top editorial priority.
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