Prognostic assessment of the combination of subclinical congestion parameters in worsening heart failure events and 90-day mortality

Introduction Readmission due to acute heart failure (AHF) attributed to residual congestion at discharge is frequent and associated with a higher risk of worsening heart failure (WHF) events. Recently, the HFA-ESC has recommended pre-discharge decongestion goals, incorporating inferior vena cava (IVC) ultrasound, lung ultrasound (LUS), and NT-ProBNP. The combination of these variables and their prognostic impact post-discharge has not been explored. Objective To evaluate the prognostic impact of a multiparametric combination of IVC, LUS, and NT-ProBNP on 90-day clinical outcomes, including AHF readmission, unplanned visits due to WHF, or all-cause mortality. Methods This substudy is derived from a randomized controlled trial that included adult patients with AHF. NT-proBNP was measured at admission and discharge, and daily IVC and lung ultrasounds were performed until discharge using a quantitative protocol. These were conducted by independent physicians not involved in patient management and reported by an external core lab composed of 3 physicians. According to the HFA-ESC consensus, patients were categorized as "Optimal" if they met the following criteria: <5 B-lines on LUS, IVC <21 mm, collapsibility index >50%, and a >30% reduction in NT-ProBNP between admission and discharge. Patients not meeting all three combined criteria were categorized as "Non-optimal." The primary endpoint was a composite of AHF readmission, unplanned visit due to WHF, or death at 90 days. Results Sixty patients were included. The mean age was 76.7 ± 13 years, 68.3% were male, and the mean left ventricular ejection fraction (LVEF) was 44% ± 15. Patients had a high prevalence of comorbidities, including hypertension (75.8%), atrial fibrillation (53%), anemia (34.8%), and chronic kidney disease (42.4%). Forty-seven percent (n=27) of the cohort was discharged under optimal decongestion criteria. A significant reduction in AHF readmission, unplanned visits due to WHF, or death at 90 days was observed in the Optimal group (Optimal 0% vs. Non-optimal 42.4%; log-rank p <0.001). Figure 2 shows the Kaplan-Meier curve for the primary endpoint, comparing the Optimal versus Non-optimal groups. Conclusion The combination of multiple subclinical congestion parameters, including IVC ultrasound, lung ultrasound, and NT-ProBNP, identified a group of AHF patients with a very low risk of WHF events and mortality at 90 days post-discharge. These findings support the most recent HFA-ESC recommendations and suggest that multiparametric assessment may be superior to individual parameter evaluation in guiding discharge timing and reducing the risk of events. Larger-scale studies are needed to validate these results and assess their impact on clinical practice.