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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e132 CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease clinical decision-making in individual patients.3–5 A weak TR signal or the presence of severe TR may result in underestimation of pulmonary systolic pressure; direct invasive measurement can resolve this uncertainty. Data from invasive measurement are essential for patients in whom the cause of pulmonary hypertension is uncertain or when assessment of pulmonary vascular reactivity after vasodilator challenge is needed. Direct measurements of right atrial pressure may also be useful for clinical decision-making. Right ventriculography may further aid in the evaluation of the severity of TR and the status of the RV. Thermodilution cardiac output measurements may be inaccurate with severe TR, and thus a Fick cardiac output should be measured to apply to the calculation of pulmonary resistance. 8.2.2 Medical Therapy Recommendations for Medical Therapy for TR COR LOE Recommendations 2a C-EO 1. In patients with signs and symptoms of right-sided HF attributable to severe TR (Stages C and D), diuretics can be useful. 2a C-EO 2. In patients with signs and symptoms of right-sided HF attributable to severe secondary TR (Stages C and D), therapies to treat the primary cause of HF (eg, pulmonary vasodilators to reduce elevated pulmonary artery pressures, GDMT for HF with reduced LVEF, or rhythm control of AF) can be useful1,2 Synopsis Diuretic therapy treats the systemic congestion in patients with severe symptomatic TR. In patients with secondary TR, treatment of the underlying primary cause may decrease the severity of the TR. Recommendation-Specific Supportive Text 1. Patients with severe TR usually present with signs or symptoms of right-sided HF, including peripheral edema and ascites. Low-salt diet and support stockings may be helpful. Diuretics can be used to decrease volume overload in these patients. Loop diuretics are typically provided and may relieve systemic congestion, but their use can be limited by worsening low-flow syndrome. Aldosterone antagonists may be of additive benefit, especially in the setting of hepatic congestion, which may promote secondary hyperaldosteronism. 2. Medical therapies for management of severe TR (Stages C and D) are limited. Attention should be focused on the underlying etiologies in patients with secondary TR. Reduction of pulmonary artery pressures and pulmonary vascular resistance with specific pulmonary vasomodulators may be helpful to reduce RV afterload and secondary TR in selected patients with pulmonary hypertension.1,2 GDMT is effective for secondary TR attributable to HF with reduced LVEF. Restoration of normal sinus rhythm may be effective for secondary TR attributable to annular dilation associated with AF.3,4 Table 20. Stages of TR Stage Definition Valve Hemodynamics Hemodynamic Consequences Clinical Symptoms and Presentation B Progressive TR Central jet <50% RA Vena contracta width <0.7 cm ERO <0.40 cm2 Regurgitant volume <45 mL None None C Asymptomatic severe TR Central jet ≥50% RA Vena contracta width ≥0.7 cm ERO ≥0.40 cm2 Regurgitant volume ≥45 mL Dense continuous wave signal with triangular shape Hepatic vein systolic flow reversal Dilated RV and RA Elevated RA with “c-V” wave Elevated venous pressure No symptoms D Symptomatic severe TR Central jet ≥50% RA Vena contracta width ≥0.7 cm ERO ≥0.40 cm2 Regurgitant volume ≥45 mL Dense continuous wave signal with triangular shape Hepatic vein systolic flow reversal Dilated RV and RA Elevated RA with “c-V” wave Elevated venous pressure Dyspnea on exertion, fatigue, ascites, edema c-V wave indicates systolic positive wave; ERO, effective regurgitant orifice; RA, right atrial; RV, right ventricular; and TR, tricuspid regurgitation. Downloaded from http://ahajournals.org by on October 7, 2026