Evolution of echographic subclinical congestion phenotypes and their prognostic impact at 90 days in acute heart failure

Introduction Residual congestion at hospital discharge is one of the main determinants of early adverse outcomes in patients with acute heart failure (AHF). Although recent HFA-ESC recommendations have promoted the use of multiparametric tools to guide decongestion, the evolution of echographic subclinical congestion phenotypes from admission to discharge and their prognostic impact have not been sufficiently explored. Objective To evaluate the evolution of echographic subclinical congestion phenotypes from admission to hospital discharge and their association with 90-day clinical outcomes. Methods This substudy was derived from a randomized controlled trial including adult patients hospitalized for AHF. Lung ultrasound (LUS) and inferior vena cava (IVC) ultrasound were performed daily using a quantitative protocol at admission and discharge. All studies were conducted by trained operators and analyzed by an independent core laboratory. Four echographic phenotypes were defined at admission and discharge: No subclinical congestion, isolated pulmonary congestion (≥5 B-lines with normal IVC), isolated systemic congestion (IVC >21 mm and collapsibility <50% with <5 B-lines) and combined pulmonary and systemic congestion. The primary endpoint was a composite of AHF readmission, unplanned visit due to worsening heart failure, or all-cause mortality at 90 days. Results Sixty patients were included (mean age 76.7±13 years; 68.3% male; mean LVEF 44%± 5). At discharge, 53.3% of patients were classified as having no congestion, 31.7% as isolated pulmonary congestion, 5% as isolated systemic congestion, and 10% as combined congestion. Event rates increased progressively according to discharge phenotype: no congestion 9.4%, pulmonary congestion 36.8%, systemic congestion 0%, and combined congestion 66.7% (global p = 0.005). Patients discharged with any degree of subclinical congestion had a significantly higher risk of 90-day events compared with those without congestion (39.3% vs 9.4%; RR 4.19; 95% CI 1.30–13.50;p=0.011).A Sankey diagram showed redistribution toward the no-congestion phenotype at discharge (53.3%). Of those admitted with congestion, 46.7% resolved, 33.3% remained congested, and 6.7% worsened. Persistent combined congestion identified the subgroup with the highest clinical risk. In trajectory analysis, complete resolution of congestion was associated with lower event incidence compared with lack of resolution (10.7% vs 34.4%;p=0.03). Kaplan–Meier curves demonstrated worst event-free survival observed in patients with combined congestion (log-rank P<0.01). Conclusion The dynamic evolution of echographic subclinical congestion phenotypes during hospitalization was associated with 90-day clinical outcomes in patients with AHF. The discharge phenotype showed a clear risk gradient according to the presence and type of residual congestion, and complete resolution of congestion was associated with lower event rates.