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 pul- monary artery pressures and pulmonary vascular resistance with specific pulmonary vasomodula- tors may be helpful to reduce RV afterload and secondary TR in selected patients with pulmo- GDMT is effective for sec- ondary TR attributable to HF with reduced LVEF. Restoration of normal sinus rhythm may be effective for secondary TR attributable to annu- lar 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 Regurgitant volume <45 mL None None C Asymptomatic severe TR Central jet 50% RA Vena contracta width 0.7 cm 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 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. CLINICAL STATEMENTS AND GUIDELINES 8.2.3. 