Medical Student The University Of British Columbia Vancouver, British Columbia, Canada
Background: Cardiac amyloidosis (CA) is a progressive infiltrative cardiomyopathy associated with poor prognosis. CA is most commonly due to transthyretin (ATTR) or light chain (AL) amyloid deposition. Tricuspid regurgitation (TR) is a common echocardiographic finding in CA; however, its prognostic relevance remains unclear. We aimed to evaluate the association between TR severity and clinical outcomes in patients with CA.
METHODS AND RESULTS: We conducted a retrospective cohort study of adults with CA referred to a specialized Cardiac Amyloidosis Clinic between January 2014–April 2024. TR severity was assessed by transthoracic echocardiography completed within 6 months of CA diagnosis and categorized as less-than-moderate versus moderate or greater. Multivariable Cox proportional hazards models were used to evaluate the association between TR severity and survival, adjusting for baseline characteristics including age, New York Heart Association (NYHA) class, estimated glomerular filtration rate (eGFR), natriuretic peptide levels (BNP or NT-proBNP), and disease stage. Among 416 patients (mean age 64.8 years, 27% AL subtype), moderate or greater TR was present in 69 (16.6%). Compared to those with less-than-moderate TR, patients with moderate or greater TR were significantly older (76.8 vs 62.4 years, P = 0.016), had lower LVEF (46.7% vs 54.4%, P < 0.0001), lower tricuspid annular plane systolic excursion (TAPSE 14.3 mm vs 18.1 mm, P < 0.0001), higher pulmonary artery systolic pressure (PASP 45.3 mmHg vs 35.7 mmHg, P < 0.0001), and worse renal function (eGFR 55.4 vs 61.5 mL/min/m2, P = 0.027). Moderate or greater TR was also associated with qualitatively more severe right ventricular dysfunction (P < 0.0001), RV dilation (incidence 49.3% vs 19.3%, P < 0.0001), and worse NYHA class (P = 0.0017). No significant associations were observed with sex, natriuretic peptide levels, troponin, amyloid subtype, or National Amyloidosis Centre stage (ATTR only). Patients with moderate or greater TR had significantly reduced survival following diagnosis (median 3.2 vs 5.4 years; log-rank P < 0.0001) (Figure 1). In adjusted Cox models, TR remained independently associated with mortality in the overall cohort (hazard ratio (HR) 1.84, P< 0.0001), ATTR subgroup (HR 1.77, P = 0.0023), and AL subgroup (HR 2.18, P < 0.0001).
Conclusion: Moderate or greater TR is independently associated with worse survival in patients with CA, regardless of amyloid subtype. These findings support routine TR severity assessment for risk stratification and to identify individuals who may benefit from closer follow-up or tailored interventions.
