POCUS-based decongestion phenotypes predicts short-term outcomes and improves risk stratification in acute decompensated heart failure

Introduction Systemic, pulmonary, and hemodynamic congestion represent complementary domains in acute decompensated heart failure (ADHF). Whether an integrated point-of-care ultrasound (POCUS)-based multiparametric assessment improves clinical characterization and risk stratification remains uncertain. Purpose To evaluate the association between early decongestion phenotypes and short-term outcomes in patients hospitalized with ADHF. Methods We prospectively enrolled consecutive adults admitted to a cardiovascular intensive care unit with ADHF and left ventricular ejection fraction (LVEF) <50%. Systemic congestion was assessed using Venous Excess Ultrasound (VExUS) score, pulmonary congestion by lung ultrasound, and hemodynamic congestion by transmitral E/e’ ratio, performed within 24 hours of admission and repeated at 72 hours. The primary outcome was in-hospital mortality. Secondary outcomes included 30-day mortality and a composite of 30-day mortality, heart transplantation (HTx), and left ventricular assist device (LVAD) implantation. Decongestion phenotypes were defined as multidomain (improvement in ≥2 domains), single-domain (improvement in 1 domain), or no decongestion (no improvement in any domain). Associations were assessed using chi-square and logistic regression. Interrelationships among domains were evaluated using Spearman correlation. Discrimination was assessed using receiver operating characteristic analysis (ROC) with calculation of area under the curve (AUC). 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]). In-hospital mortality increased progressively across decongestion phenotypes (12.0% vs 19.0% vs 57.1%; P=0.001), as did 30-day mortality (19.1% vs 23.8% vs 57.1%; P=0.018) and the composite of 30-day mortality or HTx/LVAD (25.5% vs 38.1% vs 64.3%; P=0.028). Persistent congestion independently predicted in-hospital mortality (adjusted OR 15.98, 95% CI 2.90–88.12; P=0.001), 30-day mortality (OR 9.86, 95% CI 1.99–48.78; P=0.005), and the composite outcome (OR 6.20, 95% CI 1.36–28.32; P=0.019). A significant dose–response relationship was observed, with each additional improving domain associated with a 54% reduction in in-hospital mortality (OR 0.46, 95% CI 0.26–0.82; P=0.008). Changes in pulmonary congestion correlated moderately with changes in E/e’ ratio (r=0.38, P<0.001), whereas systemic congestion showed only weak correlations with pulmonary congestion (r=0.17, P=0.092) and E/e’ ratio (r=0.14, P=0.211), supporting complementary domain behavior. When added to a clinical model including age, serum sodium, and vasopressor use, POCUS-based decongestion phenotypes significantly improved discrimination for the primary outcome (AUC 0.862 vs 0.787). Conclusions Early POCUS-based decongestion phenotypes are strongly associated with improved short-term outcomes and enhance risk discrimination beyond clinical variables in ADHF.