Integrated ultrasound haemodynamic profiling (VTI–VExUS) for risk stratification in acute heart failure

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Abstract
Aims: Clinical evaluation of congestion and perfusion in acute heart failure (AHF) has recognized limitations. Ultrasound tools such as the Venous Excess Ultrasound Score (VExUS) and the left ventricular outflow tract velocity–time integral (LVOT VTI) have gained increasing support for bedside haemodynamic profiling. We assessed the incremental prognostic value of a combined VTI–VExUS classification compared with standard clinical assessment. Methods and results: We prospectively enrolled adults admitted with AHF. Within 24 h of presentation, VExUS (congestion) and LVOT VTI (perfusion) were assessed and integrated into four ultrasound-based profiles. The primary endpoint was a 30-day composite of all-cause mortality, cardiogenic shock, mechanical ventilation, short-term ventricular assist device use, and inotropic/vasopressor therapy. Among 167 patients (mean age 58.2 ± 13.4 years; 72% male), event rates increased across VTI–VExUS profiles (11.3%, 34.6%, 32.4%, and 69.2%, P < 0.001). Discrimination was superior for the VTI–VExUS model vs. clinical assessment alone (AUC 0.74 vs. 0.58, P = 0.0016). Integrated discrimination improvement confirmed the added prognostic contribution (IDI 0.157, P = 0.004). Ultrasound profiles were independently associated with outcomes. Conclusion: VTI–VExUS ultrasound profiling provides significant incremental prognostic information beyond clinical assessment in AHF. These findings support its role as a complementary bedside tool for early risk stratification.

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