Prognostic value of combined serial changes in VExUS score and lung ultrasound in acute decompensated heart failure

Background Venous Excess UltraSound (VExUS) score and lung ultrasound (LUS) assess systemic and pulmonary congestion but are typically interpreted separately at a single timepoint, and their combined serial use remains unexplored. Purpose To investigate whether early combined changes in VExUS score and LUS predict short-outcomes in acute decompensated heart failure (ADHF). Methods We prospectively enrolled consecutive adults admitted to a cardiovascular intensive care unit with a primary diagnosis of ADHF and left ventricular ejection fraction (LVEF) <50%. VExUS score and LUS were performed within 24 h of admission and repeated after 72 hours. The variation of systemic and pulmonary congestion over 72 hours was integrated into a single metric (ΔVExPLUs = [2 × ΔVExUS] + ΔLUS), with ΔVExUS multiplied by two to balance its narrower scoring range (–3 to +3) relative to LUS (–8 to +8). The primary outcome was in-hospital mortality. Secondary outcomes included 30-day all-cause mortality and a composite of 30-day all-cause mortality, heart transplantation (HTx) and left ventricular assist device (LVAD) implantation. Associations between ΔVExPLUs improvement and outcomes were assessed using chi-square test and logistic regression. Predictive performance was evaluated by receiver operating characteristic (ROC) curve analysis with calculation of area under the curve (AUC) and diagnostic accuracy metrics. Results A total of 104 patients were included (mean age 64.3 ± 13.5 years, 69.2% male, median LVEF 24.5% [18.0, 32.0]). Improvement in ΔVExPLUs was associated with greater decongestion, including larger weight loss (–4.5 kg [–6.5, –2.4] vs. –2.2 kg [–4.6, 0.5]; P = 0.009) and greater reductions in EVEREST score (–5.0 [–9.5, –3.0] vs. –1.0 [–4.0 to 2.0]; P = 0.002). Patients with greater ΔVExPLUs improvement had lower rates of in-hospital mortality (3% vs. 46%; P < 0.001), 30-day all-cause mortality (13% vs. 50%; P = 0.008), and the composite outcome (16% vs. 64%; P < 0.001) compared with those exhibiting unchanging or worsening congestion. In multivariable analysis, ΔVExPLUs ≥ 1 independently predicted in-hospital mortality (OR 0.65; 95% CI 0.51, 0.83; P < 0.001), 30-day all-cause mortality (OR 0.78; 95% CI 0.65, 0.94; P = 0.009), and the composite outcome (OR 0.76; 95% CI 0.64, 0.92; P = 0.004). For in-hospital mortality, ΔVExPLUs achieved the highest AUC (0.76), with sensitivity 95.6% and negative predictive value 97.0%. Its superiority was consistent for 30-day all-cause mortality (AUC 0.68) and the composite outcome (AUC 0.70), whereas ΔEVEREST demonstrated poor discrimination (AUCs 0.51 to 0.55). Conclusions ΔVExPLUs was an independent predictor of short-term outcomes in ADHF, outperforming its individual components and clinical assessment. Serial integration of systemic and pulmonary ultrasound parameters may improve risk stratification during ADHF hospitalization.