In a 90-year-old patient with moderate tricuspid regurgitation (TR) and suspected hypertension with an ejection fraction (EF) > 55%, should I refer to a cardiologist or treat with diuretics?

Management of Moderate Tricuspid Regurgitation in a 90-Year-Old with Hypertension and Preserved EF

For a 90-year-old patient with moderate tricuspid regurgitation (TR), suspected hypertension, and preserved ejection fraction (>55%), diuretics should be initiated first, with cardiology referral reserved for cases that fail to respond to medical therapy.

Initial Management Approach

Medical Management (First-Line)

• Diuretic therapy is the cornerstone of treatment for patients with TR and signs of right-sided heart failure 1
  • Start with loop diuretics (e.g., furosemide) at low doses and titrate gradually
  • Consider adding aldosterone antagonists for enhanced effect, especially with hepatic congestion

Blood Pressure Control

• Optimize blood pressure management as hypertension can worsen TR
• Target systolic BP <130 mmHg as recommended for heart failure with preserved ejection fraction (HFpEF) 1
• Consider ACE inhibitors or ARBs along with beta blockers after volume status is controlled

When to Refer to Cardiology

Indications for Cardiology Referral

• Persistent symptoms despite optimal medical therapy
• Signs of progressive right ventricular dilation or dysfunction
• Worsening TR severity on follow-up echocardiography
• Development of atrial fibrillation (common in elderly with TR)

Not Recommended for Immediate Referral

• Stable moderate TR in an elderly patient with preserved EF without significant symptoms
• No evidence of right ventricular dysfunction
• Responsive to diuretic therapy

Monitoring and Follow-Up

Clinical Monitoring

• Assess for signs of right heart failure:
  • Peripheral edema, ascites, neck vein distension
  • Changes in respiratory variation of IVC diameter (diminished variation suggests volume overload) 2

Echocardiographic Surveillance

• Moderate TR should be followed with echocardiography every 1-2 years 1
• Monitor for:
  • Progression of TR severity
  • Right ventricular size and function
  • Pulmonary artery pressures

Special Considerations for Elderly Patients

Age-Related Factors

• Advanced age (90 years) significantly increases surgical risk
• Medical therapy is preferred unless severe, refractory symptoms develop
• Careful diuretic titration to avoid dehydration and electrolyte disturbances

Quality of Life Focus

• Symptom management should be prioritized over intervention in this age group
• Avoid aggressive diuresis that may lead to worsening renal function

Prognostic Implications

• Moderate-to-severe TR is associated with higher mortality in elderly patients, even with preserved EF 3
• The combination of TR and pulmonary hypertension carries a worse prognosis 4
• Careful monitoring is essential as TR severity can progress over time

Treatment Algorithm

1. Initial Assessment:

   • Confirm TR severity and rule out primary valve pathology
   • Assess for signs/symptoms of right heart failure
   • Evaluate right ventricular function

2. First-Line Treatment:

   • Start diuretics (furosemide 20-40mg daily)
   • Optimize blood pressure control

3. Reassessment (2-4 weeks):

   • If symptoms improve: continue medical therapy
   • If symptoms persist: increase diuretics, add aldosterone antagonist

4. Follow-Up (3 months):

   • If stable: continue current management
   • If worsening symptoms or RV function: refer to cardiology

This approach prioritizes symptom management and quality of life while avoiding unnecessary interventions in a very elderly patient where the risks of invasive procedures likely outweigh potential benefits.