Association of the VExUS score with right atrial pressure and organ dysfunction in acute heart failure and cardiogenic shock

Venous congestion is a major determinant of organ dysfunction in acute heart failure (AHF) and cardiogenic shock (CS). The Venous Excess Ultrasound Score (VExUS) provides a noninvasive assessment of systemic venous congestion, but its physiological correlates in the cardiac intensive care unit (CICU) remain incompletely characterized. In this prospective single-center study, 94 patients with AHF or CS underwent simultaneous VExUS assessment and invasive right atrial pressure (RAP) measurement within 24 h of CICU admission. VExUS (graded 0–3; Low 0–1 vs High 2–3) was evaluated for correlation with RAP and associations with hemodynamic, echocardiographic, and organ dysfunction indices. Prespecified RAP–VExUS phenotypes (RAP ≤ 10 vs > 10 mmHg; Low vs High VExUS) were used to assess differences in hepato–renal biochemical markers, with adjustment for relevant clinical and hemodynamic covariates. In-hospital mortality was explored using univariate logistic regression. High VExUS was present in 29 patients (31%). VExUS correlated with RAP (ρ = 0.67), inversely with the MAP–RAP gradient, and was associated with impaired right ventricular function and greater hepato–renal biochemical abnormalities, but not with lactate or urine output. RAP–VExUS discordance occurred in 30.9% of patients. Among patients with elevated RAP (> 10 mmHg), those with High VExUS showed greater hepato–renal biochemical dysfunction than those with Low VExUS ( p < 0.01). The incremental contribution of VExUS beyond RAP was mainly evident for bilirubin. In-hospital mortality was numerically higher in High versus Low VExUS patients, without reaching statistical significance (24% vs. 15%, p = 0.39). In patients with acute heart failure or cardiogenic shock, VExUS was associated with invasively measured RAP and hepato–renal biochemical abnormalities, suggesting a complementary role in congestion phenotyping alongside invasive hemodynamic assessment.