Association of pressure-adjusted heart rate with mortality in patients with significant tricuspid valve regurgitation

Background and Aims Pressure-adjusted heart rate (P-HR), defined as heart rate × (right atrial pressure (RAP)/mean arterial pressure), is an integrative haemodynamic marker that has been associated with mortality in critical illness. Its risk-stratification value in patients with significant tricuspid regurgitation (TR) is unknown. Methods and results In consecutive patients with moderate or greater TR on transthoracic echocardiography, P-HR was calculated using the echocardiographic estimate of RAP at the index study. Mean arterial pressure was estimated as (systolic blood pressure + 2 × diastolic blood pressure)/3. The primary endpoint was all-cause mortality up to 5 years. Cox regression assessed the association between P-HR and all-cause mortality. Among 12 892 patients, median P-HR was 10.1 bpm (interquartile range 6.5–15.1). Higher P-HR was associated at baseline with prevalent heart failure, renal and hepatic dysfunction, larger right ventricles, worse RV systolic function, higher RV systolic pressure, and lower stroke volume index (all P < .0001). As a continuous variable, P-HR was associated with higher risk of death (hazard ratio 1.43 per 5 bpm, 95% confidence interval 1.40–1.46; P < .0001). Addition of P-HR to a model containing age, sex, and TAPSE/right ventricular systolic pressure (RV-pulmonary artery coupling) improved mortality discrimination (C-statistic 0.630 vs 0.706, P < .0001). Conclusions In patients with significant TR, higher P-HR is progressively associated with RV dysfunction, right heart failure, and worse long-term survival. This index can be derived from routinely available vital signs and standard echocardiographic estimation of RAP; thus it may represent a practical adjunct for risk stratification in TR.