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............................................................................................................................................................................. 12.3.4 Tricuspid regurgitation Tricuspid regurgitation (TR) can be caused by or be a consequence of RV dysfunction and HF. The management of HF with TR includes MT (i.e. diuretics, neurohormonal antagonists). Transcatheter therapy and surgery may be considered in selected cases.592 A multidisciplinary Heart Team, including HF specialists, should be considered for assessment and treatment planning.

Tricuspid valve surgery is recommended in patients with severe TR requiring left-sided cardiac surgery. It should be also considered in patients with moderate TR and tricuspid annulus dilatation requiring left-sided cardiac surgery and in symptomatic patients with isolated severe TR.592 However, surgery in isolated TR is burdened by high in-hospital mortality (8.8%) although the advanced stage of HF may have influenced these data.624 Transcatheter techniques have recently emerged as potential treatment options of TR. Preliminary results show improvement in TR severity and symptoms with low complication rates.625 Further prospective studies are needed to show the prognostic impact of these treatments in HF patients.

12.4 Hypertension

Arterial hypertension is a leading risk factor for the development of HF. Almost two-thirds of HF patients have a past history of hypertension.104,626 Clinical trials evaluating antihypertensive strategies and BP targets in patients with HF and hypertension have not been performed. Treatment of HFrEF is similar in hypertensive and normotensive patients. Recommended medications, including neurohormonal antagonists and diuretics, lower also BP. Lifestyle modifications, such as weight loss, reduced sodium intake, and increased physical activity, are useful adjunctive measures.4 Uncontrolled hypertension in patients with HFrEF is rare, provided the patient is receiving OMT at recommended doses for HF. If further BP lowering is required, in absence of signs of fluid overload, amlodipine and felodipine have been shown to be safe in HFrEF and may be considered.570,571 Nondihydropyridine CCBs (diltiazem and verapamil) and centrally acting agents, such as moxonidine, are contraindicated as they are associated with worse outcomes.627 Alpha-blockers have no effects on survival and are therefore not indicated.143 They can be used for the treatment of concomitant prostatic hyperplasia but should be withdrawn in cases of hypotension. Hypertension is the most important cause of HFpEF, with a prevalence of 60% to 89%.39 Patients with HFpEF also frequently have an exaggerated hypertensive response to exercise and may present with hypertensive acute pulmonary oedema.628,629 Antihypertensive agents, including ACE-I, ARBs, beta-blockers, CCB, and diuretics reduce the incidence of HF.630,631 Reducing BP leads also to LVH regression, the degree of which depends on the class of drug used.4 ARBs, ACE-I, and CCBs cause more effective LVH regression than beta-blockers or diuretics.632 Poorly controlled hypertension may precipitate episodes of decompensation. Causes of secondary hypertension, such as renal vascular or parenchymal disease, primary aldosteronism and obstructive sleep apnoea (OSA), should be ruled out or, if confirmed, considered for treatment. Treatment of hypertension is an important issue in patients with HFpEF, but the optimal treatment strategy is uncertain. The treatment strategy used in HFrEF should also be considered in HFpEF.4 BP targets are uncertain in both HFrEF and HFpEF. However, evaluation of patient’s age and comorbidities (i.e. diabetes, CKD, CAD, valvular heart disease and stroke) can be helpful to personalize the BP target.4 Every effort should be made to reach target doses of evidence-based medications in HFrEF patients, despite slight hypotension.4,633 Conversely, in HFpEF patients with LVH and limited preload reserve, hypotension should be avoided.

12.5 Stroke

HF and stroke frequently coexist because of an overlap of shared risk factors and subsequent mechanisms.519,634 A higher risk of stroke is present also in HF patients in SR.39,426,635637 AF confers an additional risk and patients with HF and AF have a five-fold increased risk compared to the control population.519,634,638 As a temporal trend, the incidence of stroke is higher in the first 30 days after HF diagnosis or an episode of HF decompensation and decreases in the first 6 months following the acute event.637,639 Patients with stroke and HF have higher mortality, more severe neurological deficits and longer hospital stays than those without HF.637,640 Similarly, patients with HF and stroke have a higher mortality than patients without stroke.640 In COMMANDER-HF, 47.5% of strokes were either disabling, 16.5%, or fatal, 31%.637 Patients with HF and concomitant AF, including paroxysmal AF, have a CHA2DS2-VASc score of at least 1 and have therefore an indication to anticoagulation. The indication to antithrombotic strategies in patients with HF and SR is controversial. In the Warfarin and Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial, warfarin reduced ischaemic stroke as compared with aspirin, but increased major haemorrhages and did not influence the primary endpoint of ischaemic stroke, intracerebral haemorrhage, or death.641 Meta-analyses confirm an increased risk of bleeding outweighing ischaemic stroke prevention in placebo-controlled trials in patients with HFrEF and SR.642 In COMMANDER-HF, rivaroxaban 2.5 mg b.i.d. did not improve the composite outcome of all-cause mortality, MI or stroke, nor did it favourably influence HF-related deaths or HF hospitalizations.579 There are no data to support a routine strategy of anticoagulation in patients with HFrEF in SR who do not have history of paroxysmal AF. However, low-dose rivaroxaban may be considered in patients with concomitant CCS or peripheral artery disease, a high risk of stroke and no major haemorrhagic risk (see section 12.2). Patients with visible intraventricular thrombus or at high thrombotic risk, such as those with history of peripheral embolism or some patients with PPCM or LV non-compaction (LVNC), should be considered for anticoagulation.3,643645

13 Non-cardiovascular

comorbidities

13.1 Diabetes

Treatment of HF is similar in patients with and without diabetes.6,646 Conversely, antidiabetic drugs differ in their effects in patients with HF and preference must be given to drugs that are both safe and reduce HF-related events.6,646,647 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026