Anand Vidhu, Scott Christopher G, Ali Khaled, Nkomo Vuyisile T, Thaden Jeremy J, Kane Garvan C, Borgeson Daniel D, Borlaug Barry A, Pislaru Cristina, Eleid Mackram F, Crestanello Juan A, Pellikka Patricia A, Pislaru Sorin V
Department of Cardiovascular Medicine Mayo Clinic Rochester MN.
Department of Cardiovascular Medicine Mayo Clinic Health System Eau Claire WI.
J Am Heart Assoc. 2025 Jul 15;14(14):e039989. doi: 10.1161/JAHA.124.039989. Epub 2025 Jul 14.
Tricuspid valve surgery is recommended for severe isolated tricuspid regurgitation (TR) if symptoms persist despite optimal medical therapy. The definition of optimal therapy for TR is unclear beyond managing underlying conditions. Diuretics are the primary treatment for volume retention in TR, but it is unknown whether a "safe diuretic dose" exists for conservative management. We sought to evaluate the association between diuretic dose and outcomes.
Adult patients with ≥moderate-severe isolated TR were retrospectively identified from echocardiographic reports. Clinical and echocardiographic data were extracted from electronic medical records and manually reviewed. The primary end point was all-cause mortality. Loop diuretic doses were converted to furosemide equivalent and categorized into 4 groups: <40 mg, 40 to 79 mg, 80 to 159 mg, and ≥160 mg daily.
Of 1302 patients (age 72±13 years, 60% female), 565 (43%) had moderate-severe TR and 737 (57%) had severe TR. Median follow-up was 8.7 (1.4, 14.0) years. Comorbidities increased with higher diuretic doses. A linear relationship between diuretic dose and mortality was observed in spline-curve analysis. Hazard ratios (and CIs) for mortality adjusted for age, sex, coronary disease, chronic kidney disease, mild pulmonary hypertension, and New York Heart Association III/IV symptoms were 1.21 (0.96-1.53) (=0.12) for <40 mg, 1.50 (1.23-1.82) ( <0.001) for 40 to 79 mg, 1.86 (1.46-2.37) ( <0.001) for 80 to 159 mg, and 2.90 (2.18-3.88) ( <0.001) for ≥160 mg furosemide equivalent. Any diuretic dose was associated with significant symptoms (New York Heart Association III-IV), with more patients experiencing symptoms at higher doses.
A daily loop diuretic dose ≥40 mg furosemide equivalent is associated with increased mortality and greater symptom severity in patients with TR.
对于严重的孤立性三尖瓣反流（TR），如果尽管进行了最佳药物治疗症状仍持续存在，则建议进行三尖瓣手术。除了控制潜在疾病外，TR最佳治疗的定义尚不清楚。利尿剂是TR容量潴留的主要治疗方法，但保守治疗是否存在“安全利尿剂剂量”尚不清楚。我们试图评估利尿剂剂量与预后之间的关联。
从超声心动图报告中回顾性识别出患有≥中度至重度孤立性TR的成年患者。从电子病历中提取临床和超声心动图数据并进行人工审核。主要终点是全因死亡率。将袢利尿剂剂量换算为呋塞米等效剂量，并分为4组：每日<40mg、40至79mg、80至159mg和≥160mg。
在1302例患者（年龄72±13岁，60%为女性）中，565例（43%）患有中度至重度TR，737例（57%）患有重度TR。中位随访时间为8.7（1.4，14.0）年。合并症随着利尿剂剂量的增加而增加。在样条曲线分析中观察到利尿剂剂量与死亡率之间存在线性关系。根据年龄、性别、冠心病、慢性肾脏病、轻度肺动脉高压和纽约心脏协会III/IV级症状调整后的死亡率风险比（及置信区间），对于每日<40mg呋塞米等效剂量的患者为1.21（0.96-1.53）（P=0.12），对于40至79mg的患者为1.50（1.23-1.82）（P<0.001），对于80至159mg的患者为1.86（1.46-2.37）（P<0.001），对于≥160mg呋塞米等效剂量的患者为2.90（2.18-3.88）（P<0.001）。任何利尿剂剂量均与显著症状（纽约心脏协会III-IV级）相关，且剂量越高出现症状的患者越多。
对于TR患者，每日袢利尿剂剂量≥40mg呋塞米等效剂量与死亡率增加和症状严重程度加重相关。
