Determinants and prognostic value of persistent congestion assessed by venous excess ultrasound in acute heart failure

Background Venous Excess Ultrasound (VExUS) enables reliable quantification of systemic venous congestion in acute heart failure (HF). However, the prognostic significance of persistent subclinical congestion at discharge remains poorly defined. Purpose To assess the prognostic significance of persistent subclinical systemic congestion at discharge on long-term clinical outcomes. Methods All consecutive patients hospitalized for acute HF were prospectively enrolled (n=418). Comprehensive echocardiography and VExUS score were assessed at admission and prior to discharge. Subsequently, the patients were classified based on VExUS scores as: non-congested (persistent score of 0; n=81), improved (≥1-point reduction; n=214), or non-improved (persistent congestion without score reduction; n=123). MAGGIC risk score was assessed based on patients’ clinical characteristics. All patients were followed-up until the primary endpoint of all-cause mortality and HF rehospitalization. Results The patients with Non-improved VExUS had significantly higher NTproBNP, worse renal function, and received higher doses of furosemide during their hospitalization. They had significantly larger right-sided chambers, reduced right ventricular free wall longitudinal strain, higher right-ventricular systolic pressure, higher MAGGIC risk scores and a greater prevalence of severe tricuspid regurgitation compared to non-congested and to improved VExUS groups. Patients with non-improved VExUS had significantly worse event-free survival compared to patients non-congested and improved-VExUS (Figure 1). Non-improved VExUS (HR 1.77; 95% CI 1.17–2.67; p=0.007), severe tricuspid regurgitation (HR 1.88; 95% CI 1.16–3.02; p=0.010), and intravenous loop-diuretic dose (HR 1.00, 95% CI 1.00-1.01, p=0.011) were independently associated with the primary endpoint. Inclusion of VExUS non-improvement provided incremental prognostic value beyond the MAGGIC risk score, clinical, laboratory, and echocardiographic parameters (Figure 2). Conclusions Patients with VExUS non-improvement during hospitalization for acute HF, had significantly worse event-free survival compared with the improved-VExUS and the non-congested patients. Integration of VExUS dynamic changes in HF management, may enhance patient risk stratification beyond the well-recognized risk scores, clinical, biochemical and echocardiography parameters.Figure 1Figure 2