Ultrasound-guided management in heart failure: A systematic review and meta-analysis evaluating lung and inferior vena cava ultrasound for reducing readmissions and mortality

Importance Hospital admissions due to HF exacerbations often occur due to vascular congestion. With point-of-care ultrasound (POCUS) becoming more prevalent, this systematic review was performed to identify its utility by using lung and/or IVC ultrasound to visualize vascular congestion to decrease all-cause mortality and/or hospital readmissions. Objective To determine whether ultrasound-guided management using lung and/or IVC ultrasound reduces hospital readmissions and all-cause mortality in patients with HF compared to standard care. Data sources Seven RCTs, published between 2019 and 2024, were identified through systematic searches of PubMed, Embase, Web of Science, and Google Scholar. Study selection Two reviewers independently screened studies using PRISMA 2020 guidelines. Eligible studies were RCTs enrolling adults with HF in which diuretic therapy was guided by lung and/or IVC ultrasound, compared to standard care, reporting all-cause mortality or HF-related readmission. Studies were excluded if non-randomized, non-English, echocardiography-only, or involving pediatric populations. Data extraction and synthesis Data extraction was manually performed and included study characteristics, participant demographics, ultrasound modality, and outcome measures. A DerSimonian–Laird random-effects model was applied to account for clinical and methodological heterogeneity. Main outcome(s) and measure(s) The primary outcomes, planned prior to data collection, included all-cause mortality and hospital readmissions for patients admitted for HF exacerbations when utilizing ultrasound-guided management versus standard care. The data was pooled and measured using a random-effects model to calculate RR with 95% confidence intervals (CI). Results From the seven RCTs ( n = 824), ultrasound-guided management significantly reduced HF readmissions (RR = 0.61; 95% CI 0.38–0.96; p = 0.034; I 2 = 52%), corresponding to a 39% risk reduction, with a numerically larger reduction observed in the exploratory subgroup of combined lung + IVC ultrasound (RR = 0.28; 95% CI 0.13–0.60; p = 0.001; 2 trials, n = 65) compared to lung ultrasound alone (RR = 0.75; 95% CI 0.48–1.17; p = 0.211; 5 trials), though the subgroup interaction test was not statistically significant and this finding should be considered hypothesis-generating. No significant reduction in all-cause mortality was observed (RR = 0.96; 95% CI 0.58–1.58; p = 0.859; I 2 = 9%). Conclusions and relevance Seven RCTs totaling 824 patients showed that ultrasound-guided HF management significantly cut readmission risk without improving survival. A larger numerical reduction in the combined LUS + IVC subgroup is exploratory only based on two small trials and requires prospective confirmation before influencing clinical practice.