Prevalence, pattern and clinical relevance of ultrasound indices of congestion in out-patients with heart failure

Aims and methods: Even if treatment controls symptoms, patients with heart failure may still be congested. We recorded clinical and ultrasound (lung B-lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after Valsalva (JVD ratio)) features of congestion in patients with heart failure during a routine check-up to assess their prevalence, relationships and prognostic significance. Results: Of 342 patients, predominantly in NYHA I or II (257; 75%), who attended, 242 (71%) had at least one feature of congestion, either clinical (139; 41%) or by ultrasound (199; 58%). Amongst patients (n=203, 59%) clinically free of congestion, 31 (15%) had >14 B-lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (<4), 87 (43%) had at least one of these and 27 (13%) had two or more. During a median follow-up of 234 (IQR: 136-351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher NT-proBNP and IVC, and lower JVD ratio, were associated with the composite outcome. Conclusions: Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.