Tricuspid Regurgitation (TR) Digital Screening Questionnaire

Intended use: Risk stratification and echoreferral prompt
Target population: Adults ≥50 or younger adults with AF, devices, or heart failure
Completion time: 3–5 minutes
Output: Low / Moderate / High likelihood of clinically significant TR

Section 1 — Known Risk Factors

Q1. Have you ever been told you have any of the following? (Select all that apply)

Atrial fibrillation or atrial flutter Heart failure (any type) Pulmonary hypertension Prior mitral or aortic valve disease Prior heart valve surgery or transcatheter valve procedure Pacemaker or defibrillator leads crossing the heart Congenital heart disease None of the above

Section 2 — Cardinal TR Symptoms

Q2. In the past 6 months, have you experienced any of the following? (Select all that apply)

Swelling in ankles, legs, or feet Abdominal bloating or fullness not explained by diet Rapid weight gain from fluid (≥5 lb / 2 kg in 1–2 weeks) Neck vein pulsations or visible neck throbbing Early satiety or reduced appetite Increasing fatigue with routine activities Shortness of breath mainly with exertion (not chest pain)

Note: “Rapid weight gain from fluid” is included in your questionnaire, but no point value was provided in the scoring rubric, so it is scored as 0.

Section 3 — Functional Decline

Q3. Compared with 1 year ago, how has your activity level changed?

No change I get tired more easily but still do most activities I’ve stopped or reduced activities I used to do I need help with daily activities

Section 4 — TR-Specific Pattern Recognition

Q4. Which statements best describe you? (Select all that apply)

My swelling worsens later in the day Diuretics (“water pills”) help but symptoms return quickly I feel worse when my heart rhythm is irregular My symptoms have progressed slowly over years I’ve been told my heart looks “enlarged” on imaging

Section 5 — Exclusion / Competing Explanation Check

Q5. Have you been diagnosed with any of the following that fully explain your symptoms?

Advanced lung disease (COPD, pulmonary fibrosis) Liver cirrhosis or kidney failure Venous insufficiency only None of the above

Edwards