A JACC State-of-the-Art review explores the relationship between severe, symptomatic tricuspid regurgitation (TR) and advanced heart failure with preserved ejection fraction (HFpEF) and proposes strategies for optimizing patient care and outcomes.

As part of the review, Rebecca T. Hahn, MD, FACC, et al., highlight the "similarities of predictive parameters as well as common clinical presentation" that have led investigators to presume that HFpEF and TR may indeed be related.

Specifically, they compare risk factors of both TR and HFpEF, and highlight commonalities, including sex (female), pulmonary artery systolic pressure ≥36 mm Hg, left atrial enlargement; age ≥70 years; and history of atrial fibrillation (AFib). They also note that the increasing commonality of biatrial myopathy in HFpEF patients has been found to be associated with increased prevalence of significant TR.

The authors propose a diagnostic and management algorithm for use when caring for patients experiencing both conditions that involves excluding other causes of heart failure, diagnosing HFpEF and relevant comorbidities, and then diagnosing severe, symptomatic TR. The strategy strongly recommends use of SGLT2is, HF self-care plan education, loop diuretics for patients with fluid overload, and guideline-recommend hypertension management, along with other potential considerations. Nitrates, sildenafil and soluble guanylate cyclase stimulators, as well as rate-adaptive atrial pacing in the incidence of chronotropic incompetence are identified and possibly harmful or of no benefit.

Looking ahead the authors suggest that "earlier diagnosis of both HFpEF and valvular heart disease holds promise for improving outcomes for our patients before progression to irreversible stages." In addition to machine learning and deep learning potentially aiding in earlier diagnosis, "understanding the relationship between HFpEF and TR also may impact future trial designs, as well as management decisions for the multidisciplinary heart team," they say.