Clinical Investigations
Tricuspid Regurgitation and Outcomes
Adverse Prognostic Impact of Even Mild or Moderate Tricuspid Regurgitation: Insights from the National Echocardiography Database of Australia

https://doi.org/10.1016/j.echo.2022.04.003Get rights and content

Highlights

  • We studied a large group of adults referred for echocardiography.

  • Moderate or greater all-cause TR is prevalent and associated with poor prognosis.

  • There is a stepwise progression of mortality risk with increasing grades of TR.

  • Even mild TR is independently associated with intermediate prognosis.

  • Poor prognosis is independent of AF, pulmonary hypertension, or left heart disease.

Background

The prevalence and prognostic impact of tricuspid regurgitation (TR) remain incompletely characterized.

Methods

The distribution of TR severity was analyzed in 439,558 adults (mean age, 62.1 ± 17.8 years; 51.5% men) being investigated for heart disease, from 2000 to 2019, by 25 centers contributing to the National Echocardiography Database of Australia. Survival status and cause of death were ascertained in all adults from the National Death Index of Australia. The relationship between TR severity and mortality was examined.

Results

Of those studied, 311,604 (70.9%) had no/trivial TR; 94,172 (21.4%), mild TR; 26,056 (5.9%), moderate TR; and 7,726 (1.8%), severe TR. During a median 4.1 years (interquartile range, 2.2-7.0 years) of follow-up, 109,004 died (49% from cardiovascular causes). Moderate or greater TR was associated with older age and female sex (P < .001). Individuals with moderate and severe TR had a 2.0- to 3.2-fold increased risk of all-cause long-term mortality after adjustment for age and sex compared with those with no/trivial TR (P < .001 for both comparisons). Even those with mild TR had a significantly increased risk for mortality (hazard ratio [HR] = 1.29; 95% CI, 1.27-1.31). In fully adjusted models, including for RV systolic pressure, atrial fibrillation, and significant left heart disease, there remained a 1.24- to 2.65-fold increased risk of mortality with mild (HR = 1.24; 95% CI, 1.23-1.26), moderate (HR = 1.72; 95% CI, 1.68-1.75), or severe TR (HR = 2.65; 95% CI, 2.57-2.73), compared with those with no/trivial TR (P < .001 for all).

Conclusions

Tricuspid regurgitation is a common condition in adults referred for echocardiography. Moreover, even in the presence of other cardiac disease, increasing grades of TR are independently associated with increasing risks of cardiovascular and all-cause mortality. Furthermore, we show that even mild TR is independently associated with a significant increase in mortality.

Section snippets

Study Setting and Design

As described elsewhere,19 the NEDA database is a large observational registry capturing individual echocardiographic data, as well as basic demographic profiling, from over 25 participating centers throughout Australia. Centers include a range of public and private hospitals and inpatient and outpatient echocardiography laboratories and are situated in both urban and rural settings across the entire country. Individuals are referred by primary care physicians or cardiologists to investigate

Cohort Profile

In our final analysis cohort of 439,558 individuals, the mean age was 62.1 ± 17.8 years and the cohort included 213,186 (48.5%) women. Basic demographic, clinical, and echocardiographic data of the patient cohort are summarized in Table 1. No/trivial TR was reported in 311,604 (70.9%; 95% CI, 70.1%-71%) cases. Mild TR was reported in 94,172 (21.4%; 95% CI, 21.3%-21.5%), moderate TR in 26,056 (5.9%; 95% CI, 5.8%-6.0%), and severe TR in 7,726 (1.8%; 95% CI, 1.7%-1.8%), for a combined total of

Discussion

In this very large study of adults undergoing echocardiography, we found that TR in mild or greater degree was not only common (nearly one-third of the studied cohort had mild or greater TR) but that there was also a significant and graded association between the severity of TR and the risk of mortality. Even mild TR had independent prognostic significance. With more than 12 times as many identified cases of significant TR compared with any previous report, this study provides a unique

Conclusion

The scale of the NEDA database provides a unique opportunity to evaluate both the prevalence and the prognostic significance of TR in a very large cohort of adults undergoing cardiac investigation with echocardiography. We demonstrate that not only is moderate or greater TR prevalent (7.7% of individuals in our real world cohort) but that there is a significant stepwise increase in both short- and long-term mortality with increasing severity of TR. Even mild TR has independent prognostic

Acknowledgments

We thank all the NEDA centers and their patients for contributing to these data.

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    Conflicts of Interest: None.

    The National Echocardiography Database of Australia (NEDA) was originally established with funding support from Actelion Pharmaceuticals, Bayer Pharmaceuticals, GlaxoSmithKline. NEDA (no. 1055214) and S.S. are (GNT1135894) supported by the National Health and Medical Research Council of Australia. NEDA has received grants from Edwards Lifesciences, but they do not relate to the current manuscript.

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