Association of pressure-adjusted heart rate with heart failure and long-term mortality in patients with significant tricuspid valve regurgitation

Background Tricuspid valve regurgitation (TR) is a common valvular disease associated with increased mortality. Effective and timely risk stratification guides management decisions. Pressure-adjusted heart rate (P-HR) is a simple haemodynamic parameter used in critical care setting and has been shown to correlate with mortality in various intensive care unit populations. Whether this simple index can stratify risk in patients with significant TR is untested. Purpose To assess the association of P-HR with disease severity and 5-year outcomes in patients with ≥ moderate TR. Methods In consecutive patients with ≥ moderate TR on echocardiography, P-HR was calculated as heart rate × (estimated right atrial pressure/mean arterial pressure). Heart rate and blood pressure were recorded at the time of echocardiography; mean arterial pressure was estimated as (systolic blood pressure + 2×diastolic blood pressure)/3. Right atrial pressure was estimated echocardiographically. All-cause mortality at 5 years was assessed with Cox regression. Results Among 12,750 patients studied, median P-HR was 10.4 bpm (IQR 6.5, 15.6) (Figure 1). Higher P-HR was associated with heart failure, hepatic and renal disease and clinical markers of risk such as the Tricuspid Regurgitation Impact on Outcomes (TRIO) score, larger right ventricular (RV) size, worse RV systolic function, higher NT-proBNP and clinical features of right heart failure (Table). After adjusting for age and sex, increasing P-HR was associated with an increased risk of death (HR 1.43 (95% confidence intervals 1.40-1.46) per 5 bpm; p<.0001; Figure 1). A multivariable model containing P-HR in addition (C-statistic 0.706) showed increased discrimination for mortality than age, sex, and tricuspid plane systolic excursion (TAPSE)/RV systolic pressure alone (C-statistic 0.630) suggesting incremental value over a standard measure of right ventriculoarterial coupling. Conclusion(s) In patients with significant TR, higher P-HR is progressively associated with RV dysfunction, right heart failure, and worse survival. Incorporating P-HR into the routine assessment of patients may help stratify risk in patients with significant TR.FigureTable