Secondary mitral regurgitation (SMR) is a complex and evolving challenge in the landscape of heart failure (HF) management. Although significant secondary MR has been widely recognised for its adverse outcomes, moderate SMR has historically been considered a more benign entity. However, recent evidence, including the manuscript we are referring to,1 suggests that moderate SMR may not be as innocent as previously thought. Patients with moderate SMR experience high rates of HF events and all-cause mortality during long-term follow-up, highlighting the need for more aggressive and personalised management strategies.2

As the clinical understanding of SMR evolves, so too does the debate over the optimal treatment strategy.3 Should we continue with a conservative, stepwise approach, beginning with pharmacological management and delaying intervention until MR severity worsens? Or should we adopt an integrated approach, incorporating early mitral valve intervention, especially for patients with persistent symptoms despite optimal medical therapy? To answer these questions, we must consider the evidence from clinical trials like RESHAPE-HF 2 and the unique challenges presented by moderate SMR.4

The manuscript just published in Heart provides valuable insights into the prognosis of patients with moderate SMR.1 A cohort of 1061 patients with moderate SMR was followed for a median of 82 months, during which 37% of patients died, and 51% experienced HF events or death. These findings underscore the fact that moderate SMR is not a benign condition. Even patients with preserved left ventricular ejection fraction (LVEF) are at risk of adverse outcomes, particularly when SMR is of ventricular origin (ventricular SMR; vSMR), which is associated with worse survival compared with atrial SMR (aSMR)1 (figure 1).

Stepwise approach versus integrated management.

These data align with …