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Tricuspid Regurgitation Impact on Outcomes (TRIO): A Simple Clinical Risk Score



      To determine which clinical variables infer the highest risk for mortality in patients with notable tricuspid regurgitation (TR) and to develop a clinical assessment tool (the Tricuspid Regurgitation Impact on Outcomes [TRIO] score).

      Patients and Methods

      A single-center retrospective cohort of 13,608 patients with undifferentiated moderate to severe TR at the time of index echocardiography between January 1, 2005, and December 31, 2016, was included. Baseline demographic and clinical data were obtained. Patients were randomly assigned to a training (N=10,205) and a validation (N=3403) cohort. Median follow-up was 6.5 years (interquartile range, 0.8 to 11.0 years). Variables associated with mortality were identified by Cox proportional hazards methods. A geographically distinct cohort of 7138 patients was used for further validation. The primary end point was all-cause mortality over 10 years.


      The 5-year probability of death was 53% for moderate TR, 63% for moderate-severe TR (hazard ratio [HR], 1.24 [95% CI, 1.17 to 1.31]; P<.001 vs moderate), and 71% for severe TR (HR, 1.55 [95% CI, 1.47 to 1.64]; P<.001 vs moderate). Factors associated with all-cause mortality on multivariate analysis included age 70 years or older, male sex, creatinine level greater than 2 mg/dL, congestive heart failure, chronic lung disease, aspartate aminotransferase level of 40 U/L or greater, heart rate of 90 beats/min or greater, and severe TR. Variables were assigned 1 or 2 points (HR, >1.5) and added to compute the TRIO score. The score was associated with all-cause mortality (C statistic = 0.67) and was able to separate patients into risk categories. Findings were similar in the second, independent and geographically distinct cohort.


      The TRIO score is a simple clinical tool for risk assessment in patients with notable TR. Future prospective studies to validate its use are warranted.

      Abbreviations and Acronyms:

      AF (atrial fibrillation), AST (aspartate aminotransferase), CHF (congestive heart failure), HR (hazard ratio), LCL (lower control limit), TR (tricuspid regurgitation), TRIO (Tricuspid Regurgitation Impact on Outcomes), UCL (upper control limit)
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      Linked Article

      • TRIO Risk Score: Simple, Yet Complex
        Mayo Clinic ProceedingsVol. 97Issue 8
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          Tricuspid regurgitation (TR) occurs in 65% to 85% of the population in the United States.1,2 Although mild TR in the setting of a structurally normal tricuspid valve apparatus can be considered a normal variant, progression to moderate-severe TR increases with age and is estimated to affect nearly 1.6 million adults in the United States.3 Echocardiographic data from the Framingham Heart Study reported an overall prevalence of moderate or higher TR of 0.8%, with a majority due to functional TR and only 10% due to an organic cause.
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