Combined mitral and tricuspid regurgitation as a major determinant of rehospitalization in elderly patients with HFpEF

Background Predictors of rehospitalization in heart failure with preserved ejection fraction (HFpEF) remain incompletely defined. Structural abnormalities such as valvular regurgitation and atrial enlargement may have different prognostic implications across age groups. Purpose To identify clinical and echocardiographic predictors of heart failure rehospitalization in HFpEF and to assess whether their prognostic relevance differs according to age. Methods We conducted a retrospective cohort study including 622 patients with HFpEF and a mean follow-up of 4 years. Time to first heart failure hospitalization was analysed using Cox proportional hazards models. Clinical, laboratory and echocardiographic variables were evaluated, including age, sex, renal function, atrial fibrillation (AF), NT-proBNP (log-transformed), left ventricular ejection fraction (LVEF), left atrial diameter indexed in 5-mm increments, and a combined mitral/tricuspid regurgitation more than mild ("valve burden") score. Age-stratified analyses (<75 vs ≥75 years) were performed. Kaplan–Meier curves with log-rank testing were used to compare event-free survival across valve burden score categories in the overall cohort and stratified by age. Results Over a mean follow-up of 49 ± 16 months, 181 patients (29.1%) were rehospitalised. In the overall cohort, LVEF was inversely associated with rehospitalization (hazard ratio [HR] 0.95 per 1% increase, p=0.017) and higher valve burden score independently predicted heart failure hospitalization (HR 1.43 per unit, p=0.001). AF and left atrial diameter were not independently associated after multivariable adjustment. In patients aged <75 years, only LVEF remained an independent predictor (p<0.005). In contrast, in patients aged ≥75 years, valve burden score (HR 1.60, p=0.003) and left atrial diameter (HR 1.14 per 5-mm increase, p=0.037) independently predicted hospitalization, while LVEF lost prognostic significance. Kaplan–Meier analysis showed graded reduction in event-free survival across increasing valve burden score categories in the overall cohort (log-rank p<0.001), with significant separation in both patients <75 years (p=0.006) and ≥75 years (p<0.001). Conclusions In HFpEF, determinants of rehospitalization differ according to age. In younger patients, risk is primarily driven by left ventricular systolic function, whereas in older patients it is dominated by structural cardiac remodeling reflected by combined mitral and tricuspid regurgitation and atrial enlargement. These findings support age-adapted risk stratification in HFpEF.