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  • Population-Based Study: New-Onset AF without Structural Heart Disease Increases Risk for Incident TR

    The study also found that tricuspid regurgitation predicts mortality

    Among patients without structural heart disease, atrial fibrillation (AF) leads to increased incidence of moderate or greater tricuspid regurgitation (TR), and isolated TR or moderate or greater TR is associated with long-term mortality, according to a population-based study utilizing a record linkage system.

    Sri Harsha Patlolla, MBBS, MS of the Mayo Clinic in Rochester, Minnesota, and colleagues reported these findings in a manuscript published Monday online and in the Dec. 13issue of the Journal of the American College of Cardiology.

    The majority of TR cases are secondary to left heart disease or pulmonary hypertension. Isolated TR, without evidence of secondary causes, is plausibly due to AF; however, prior studies have not demonstrated a clear causative relationship.

    Patlolla and colleagues aimed to investigate the relationship of new-onset AF with incident TR in patients without significant structural disease, that is, without evidence of moderate or greater tricuspid valve disease, left-sided valve disease, pulmonary hypertension, prior cardiac surgery or impaired left ventricular systolic/diastolic function at baseline.

    The group utilized a population-based record linkage system, the Rochester Epidemiology Project, to ensure complete and accurate ascertainment of new-onset AF, incident TR and other outcomes. The study included 691 patients.

    At baseline, the patients’ median age was 68.0 years (interquartile range [IQR]: 58.0–76.0 years), 38.9% were female, and their median body mass index was 29.5 kg/m2 (IQR: 26.0–34.0 kg/m2). The most common comorbidities were hyperlipidemia (70.3%), hypertension (68.5%), and diabetes (41.5%),

    Patients were followed for a median 13.3 years (IQR: 10.0-15.9 years). During that time,  232 (33.6%) patients developed moderate or greater TR, and 73 (10.6%) had isolated TR. The incidence rate of moderate or greater TR was 3.9 cases per 100 person-years, and that of isolated TR was 1.3 cases per 100 person-years.

    Permanent/persistent AF and female sex were associated with increased risk of developing TR, while rhythm control was associated with lower risk of TR. Increased risk of long-term mortality occurred with moderate or greater TR (hazard ratio [HR]: 2.92; 95% confidence interval [CI]: 2.29-3.73; P < 0.001) and isolated significant TR (HR: 1.51; 95% CI: 1.03-2.22; P =0.03).

    Tobias Friedrich Ruf, MD of the University Medical Center Mainz, Germany, and colleagues wrote the editorial comment. The editorialists emphasized the study’s intriguing findings that sustained AF, compared to paroxysmal AF, greatly increased risk of incident TR, as did female sex, whereas rhythm control reduced the risk of TR.

    They cited evidence that the sex disparity for incident TR may be partially explained by morphologic and cellular differences on the tricuspid annulus. Further, they explained that this study supports AF as a causative mechanism for isolated TR.

    The commenters wrote: “One wonders if ‘isolated TR’ might be renamed “atrial [TR of a secondary origin]’ in the future …”


    Patlolla SH, Schaff HV, Nishimura RA, et al. Incidence and Burden of Tricuspid Regurgitation in Patients With Atrial Fibrillation. J Am Coll Cardiol 2022;80:2289–2298.

    Ruf TF, Gößler TAM, von Bardeleben RS. Understanding Atrial Fibrillation and Atrial Secondary Tricuspid Regurgitation: The Chicken or the Egg?. J Am Coll Cardiol 2022;80:2299–2300.

    Image Credit: sudok1 –

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