Redefining Nohria's clinical profile classification in acute heart failure with bedside ultrasound: the ITV/VExUS index - a call for new directions

Background Hemodynamic profiling in acute cardiovascular care has been essential in acute heart failure (AHF) for prognosis and decision-making. Traditional, invasive, methods have limitations, while non-invasive imaging, like echocardiography and lung ultrasound, offers a promising alternative, highlighting the need for an improved classification system. Purpose This study aims to reclassify the Nohria profile using VExUS protocol and VTI LVOT to assess major adverse cardiovascular events (MACE) in acute heart failure (AHF) patients and evaluate its prognostic value. Methods A retrospective single-centre study was conducted with adult AHF patients who underwent bedside echocardiography within 24 hours of admission. The VExUS protocol and VTI LVOT measurements were used to reclassify the Nohria profiles into four categories based on congestion and hypoperfusion. The primary endpoint was the occurrence of MACE within 30 days. The secondary endpoint compared the prognostic accuracy of VTI/VExUS index with traditional clinical assessment using ROC curve analysis. Results A total of 167 patients were included, with a mean age of 58.2 years, and 72.4% were male. Distribution across the Nohria profiles was as follows: 46.7% in Profile 0, 15.6% in Profile 1, 22.1% in Profile 2, and 15.6% in Profile 3. The VTI/VExUS-based classification showed an AUC of 0.74 (95%) for predicting MACE, compared to 0.58 (95%) for the adapted Nohria classification. During the 30-day follow-up, 48 patients (28.5%) experienced MACE, including 13 deaths (7.7%), 23 cases of cardiogenic shock (13.8%), 43 requiring mechanical ventilation (25.9%), 13 requiring a ventricular assist device (7.7%), and 71 requiring inotropes (42.7%). Kaplan-Meier survival curves indicated significantly poorer outcomes for Profile 3, with a higher incidence of MACE. Log-rank test showed a significant prognostic difference between VTI/VExUS profiles (HR 1.93, 1.49–2.49, P <0.001). Conclusion The VTI/VExUS index demonstrated that it redefines Nohria’s profiles, improving prognostic accuracy compared to traditional methods. This non-invasive tool has the potential to enhance clinical decision-making and patient outcomes. However, further research is needed to confirm its validity and broader applicability in clinical practice.