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

Q: What are the key findings of this study?

The VExUS score strongly correlated with invasively measured right atrial pressure (ρ = 0.67, p < 0.001) and was associated with greater hepato-renal biochemical dysfunction in CICU patients.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute heart failure or cardiogenic shock (n=94). Intervention: High Venous Excess Ultrasound Score (VExUS grade 2–3) vs. Low Venous Excess Ultrasound Score (VExUS grade 0–1). Primary outcome: Correlation and association between VExUS grade (0–3; High 2–3 vs Low 0–1) and simultaneously invasively measured right atrial pressure (RAP, mmHg) (Spearman ρ = 0.67, p=<0.001).

Q: What does this research mean for the field?

In patients with acute heart failure and cardiogenic shock, the Venous Excess Ultrasound Score (VExUS) correlates with invasively measured right atrial pressure and provides complementary information on hepato-renal organ dysfunction. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the physiological correlates of the Venous Excess Ultrasound Score (VExUS) and its association with invasively measured right atrial pressure and organ dysfunction in the cardiac intensive care unit.

Simone Filomia; Marco Giuseppe Del Buono; Daniela Pedicino; Gianluigi Saponara; Alessia d’Aiello; Sofia Morini; Mattia Brecciaroli; Marta Ricci; Chiara Simonini; Gaetano Pinnacchio; Lorenzo Genuardi; Rocco Antonio Montone; Tommaso Sanna

doi:10.1038/s41598-026-75984-1

October 21, 2026Scientific ReportsOpen Access

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

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Key result

Higher VExUS scores strongly correlate with invasively measured RAP and hepato-renal dysfunction in CICU patients.

Spearman ρ = 0.67
P<0.001
n=94

Why the study?

The Venous Excess Ultrasound Score provides a noninvasive assessment of systemic venous congestion in AHF and cardiogenic shock, but its physiological correlates in the cardiac intensive care unit remained incompletely characterized.

Does the noninvasive Venous Excess Ultrasound Score (VExUS) correlate with invasively measured right atrial pressure and identify hepato-renal organ dysfunction in patients admitted to the CICU with acute heart failure or cardiogenic shock?

Key Points

To evaluate the physiological correlates of the Venous Excess Ultrasound Score (VExUS) and its association with invasively measured right atrial pressure and organ dysfunction in the cardiac intensive care unit.
Prospective single-center study of 94 patients with acute heart failure or cardiogenic shock admitted to a cardiac intensive care unit.
Patients underwent simultaneous VExUS grading (0–3; categorized as Low 0–1 vs High 2–3) and invasive right atrial pressure (RAP) measurement within 24 hours of admission.
Associations between RAP–VExUS phenotypes and hepato-renal biomarkers were assessed after adjustment for positive-pressure ventilation and SCAI stage, alongside exploratory logistic regression for in-hospital mortality.
High VExUS was identified in 29 patients (31%) and correlated with RAP (ρ = 0.67, p < 0.001) and lower MAP–RAP gradient; discordance between RAP and VExUS classifications occurred in 30.9% of patients.
Among patients with elevated RAP (> 10 mmHg), High VExUS was linked to greater hepato-renal biochemical dysfunction (p < 0.01), providing significant incremental explanatory value beyond RAP for bilirubin (ΔR2 = 0.074, p = 0.006) but not for creatinine or ALT.
In-hospital mortality was numerically higher in patients with High versus Low VExUS (24.1% vs 15.4%, p = 0.388), though neither VExUS nor RAP showed a statistically significant link to mortality.

Study Design

Type

Cohort (n=94)

Blinding

VExUS operators were not formally blinded to invasive RAP values or other clinical information

Multicenter

No

Structured PICO

Does the noninvasive Venous Excess Ultrasound Score (VExUS) correlate with invasively measured right atrial pressure and identify hepato-renal organ dysfunction in patients admitted to the CICU with acute heart failure or cardiogenic shock?

P

Population

94 adults (median age 70 years, 71.3% male) admitted to a single-center tertiary CICU in Italy with acute heart failure or cardiogenic shock, assessed within 24 hours of admission and followed during hospitalization.

E

Exposure

Venous Excess Ultrasound Score (VExUS) assessment (graded 0–3; categorized as Low VExUS [0–1] vs High VExUS [2–3]) using a standardized stepwise protocol integrating inferior vena cava diameter and pulsed-wave Doppler of the hepatic, portal, and intrarenal veins, performed simultaneously with invasive right atrial pressure (RAP) measurement within 24 hours of CICU admission.

C

Comparator

Invasive right atrial pressure (RAP) measurement (categorized as ≤10 mmHg vs >10 mmHg) obtained via central venous catheter or pulmonary artery catheter, and comparison between Low VExUS (0–1, n=65) and High VExUS (2–3, n=29) groups.

O

Outcome

Correlation between VExUS grade (0–3) and simultaneously invasively measured right atrial pressure (RAP), as well as concordance and discordance between RAP (≤10 vs >10 mmHg) and VExUS (0–1 vs 2–3) phenotypes within 24 hours of CICU admission.surrogate

Main Result

Effect estimate: Spearman ρ = 0.67

Absolute Event Rate: 15% vs 9%

p-value: p=<0.001

In CICU patients with acute heart failure or cardiogenic shock, VExUS strongly correlates with invasively measured right atrial pressure and identifies a higher burden of hepato-renal biochemical dysfunction beyond RAP alone, supporting its complementary use for congestion phenotyping.

Limitations

Single-center study with modest sample size (n=94) and few mortality events, limiting prognostic power
Each VExUS examination was performed by a single unblinded operator, precluding interobserver reproducibility assessment
In mechanically ventilated patients, RAP was not corrected for positive end-expiratory pressure (PEEP)
VExUS and RAP were assessed at a single time point within 24 hours of admission, introducing potential temporal mismatch with biochemical markers
Non-standardized therapeutic management and missing forward-flow parameters (such as cardiac output) in some patients
Single-center study with a modest sample size and limited number of events, not powered for prognostic/mortality assessment.
Each VExUS examination was performed by a single experienced operator, precluding formal assessment of interobserver reproducibility.
VExUS operators were not formally blinded to invasive RAP values or other clinical information.
VExUS, RAP, and biochemical markers were assessed at a single time point within 24 hours of admission, which may reflect effects of early therapeutic interventions.
In mechanically ventilated patients, RAP was not corrected for positive end-expiratory pressure (PEEP).

Implication

May refine venous congestion assessment in CICU; leaves open whether VExUS improves outcomes over RAP.

Abstract

Background 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. Methods 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 hours 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 positive pressure ventilation and SCAI stage. In-hospital mortality was explored using univariate logistic regression. Results 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 higher hepato–renal dysfunction biomarkers, 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 = NS). Conclusions In patients with acute heart failure or cardiogenic shock, VExUS was associated with invasively measured RAP and hepato-renal biochemical dysfunction, suggesting a complementary role in congestion phenotyping alongside invasive hemodynamic assessment.

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Cite This Study

Filomia et al. (2026) conducted a cohort in Acute heart failure or cardiogenic shock (n=94). High Venous Excess Ultrasound Score (VExUS grade 2–3) vs. Low Venous Excess Ultrasound Score (VExUS grade 0–1) was evaluated on Correlation and association between VExUS grade (0–3; High 2–3 vs Low 0–1) and simultaneously invasively measured right atrial pressure (RAP, mmHg) (Spearman ρ = 0.67, p=<0.001). The VExUS score strongly correlated with invasively measured right atrial pressure (ρ = 0.67, p < 0.001) and was associated with greater hepato-renal biochemical dysfunction in CICU patients.

synapsesocial.com/papers/6ae28dedcbadf70daf6c3f22 https://doi.org/10.1038/s41598-026-75984-1

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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