Ultrasound-derived congestion phenotypes and their association with cardiac structure and function in HFpEF

Abstract

Aim: To evaluate ultrasound-derived congestion phenotypes in acute decompensated heart failure with preserved ejection fraction (HFpEF) and their association with cardiac remodeling and in-hospital outcomes.

Methods: This prospective study included 235 patients (median age 77.0 years, 75.3% women) with acute decompensated HFpEF. Within 2 hours of admission, all patients underwent echocardiography, lung ultrasound (B-lines), venous excess ultrasound score (VExUS) assessment, and bioimpedance analysis. Patients were classified into three phenotypes based on pulmonary (B-lines > 3) and systemic venous congestion (VExUS): low-low (no significant pulmonary or systemic congestion), pulmonary-dominant, and mixed severe. The primary endpoint was in-hospital mortality.

Results: Moderate-to-severe venous congestion (VExUS grade 2–3) was present in 60.8% of patients. The mixed severe phenotype predominated (60.9%) and was associated with higher body mass index (BMI) and waist (p < 0.001). This group demonstrated more advanced cardiac dysfunction, including higher E/e’ (14.9 vs. 11.9; p < 0.001), greater left atrial remodeling (left atrial volume index 45.0 vs. 39.0 mL/m²; p < 0.001), and increased left ventricular mass index (p = 0.010). Right ventricular (RV) involvement was more pronounced, with lower TAPSE (18.0 vs. 20.0 mm; p < 0.001) and higher tricuspid regurgitation velocity (p < 0.001). Markers of congestion showed a gradient, with higher NT-proBNP (3,072.5 vs. 1,197.0 pg/mL; p < 0.001), increased extracellular water (129% vs. 101%; p < 0.001), and lower phase angle (4.9 vs. 5.5; p < 0.001). In-hospital mortality was highest in the mixed severe phenotype [11.2% vs. 3.0% and 1.7%; p = 0.039; odds ratio (OR) 5.67]. B-lines correlated with tricuspid regurgitation velocity, E/e’, and extracellular water (all r ≥ 0.50).

Conclusions: Ultrasound-derived congestion phenotyping in HFpEF identifies distinct profiles associated with atrial and ventricular remodeling and worse in-hospital outcomes. Future studies are required to determine whether phenotype-guided decongestive strategies can improve outcomes beyond risk stratification.

Keywords

HFpEF / congestion / echocardiography / left atrium / right ventricle / VExUS / lung ultrasound

References

[1] Canepa M, Kapelios CJ, Benson L, Savarese G, Lund LH. Temporal Trends of Heart Failure Hospitalizations in Cardiology Versus Noncardiology Wards According to Ejection Fraction: 16-Year Data From the SwedeHF Registry. Circ Heart Fail. 2022; 15: e009462.

[2] Grigore M, Nicolae C, Grigore AM, Balahura AM, Păun N, Uscoiu G, et al. Contemporary Perspectives on Congestion in Heart Failure: Bridging Classic Signs with Evolving Diagnostic and Therapeutic Strategies. Diagnostics (Basel). 2025; 15: 1083.

[3] Van Aelst LNL, Arrigo M, Placido R, Akiyama E, Girerd N, Zannad F, et al. Acutely decompensated heart failure with preserved and reduced ejection fraction present with comparable haemodynamic congestion. Eur J Heart Fail. 2018; 20: 738-47.

[4] Palazzuoli A, Evangelista I, Beltrami M, Pirrotta F, Tavera MC, Gennari L, et al. Clinical, Laboratory and Lung Ultrasound Assessment of Congestion in Patients with Acute Heart Failure. J Clin Med. 2022; 11: 1642.

[5] Koratala A, Romero-González G, Soliman-Aboumarie H, Kazory A. Unlocking the Potential of VExUS in Assessing Venous Congestion: The Art of Doing It Right. Cardiorenal Med. 2024; 14: 350-74.

[6] Palazzuoli A, Ruocco G, Pellicori P, Gargani L, Coiro S, Lamiral Z, et al. Multi-modality assessment of congestion in acute heart failure: Associations with left ventricular ejection fraction and prognosis. Curr Probl Cardiol. 2024; 49: 102374.

[7] Dzhioeva ON, Rogozhkina EA, Ivanova AA, Vedenikin TY, Drapkina OM. Ultrasound-assisted diagnosis of decompensated heart failure in general practice. Guideline. Primary Health Care (Russ Fed). 2026; 2: 112-37.

[8] Beaubien-Souligny W, Rola P, Haycock K, Bouchard J, Lamarche Y, Spiegel R, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020; 12: 16.

[9] de la Espriella R, Santas E, Zegri Reiriz I, Górriz JL, Cobo Marcos M, Núñez J. Quantification and Treatment of Congestion in Heart Failure: A Clinical and Pathophysiological Overview. Nefrologia (Engl Ed). 2022; 42: 145-62.

[10] Sohn S, Jeon J, Lee JE, Park SH, Kang DO, Park EJ, et al. Phase angle in bioelectrical impedance analysis for assessing congestion in acute heart failure. PLoS One. 2025; 20: e0317333.

[11] Shirokov NE, Yaroslavskaya EI, Krinochkin DV, Kosterin MD, Musikhina NA. Diagnostic value of left atrial compliance in determining heart failure with preserved ejection fraction. Russ Open Med J. 2024; 13: e0409.

[12] Obokata M, Reddy YNV, Pislaru SV, Melenovsky V, Borlaug BA. Evidence Supporting the Existence of a Distinct Obese Phenotype of Heart Failure With Preserved Ejection Fraction. Circulation. 2017; 136: 6-19.

[13] Bogdanova TM, Gorbunova LA, Goryachev VS, Fedonnikov AS. Low LDL levels are associated with the absence of dyspnea in patients with chronic heart failure. Russ Open Med J. 2025; 14: e0413.

[14] Rubanenko OA, Rubanenko AO, Duplyakov DV. Factors associated with mortality in patients with chronic heart failure during an 18-month follow-up period. Russ Open Med J. 2025; 14: e0409.

[15] Parizad R, Hatwal J, Taban Sadeghi M, Brar A, Desai R, Batta A, et al. Clinical Advances in Heart Failure with Preserved Ejection Fraction: A Systematic Review of Therapeutic and Mechanistic Evidence. Vasc Health Risk Manag. 2026; 22: 578698.

[16] Brar AS, Khanna T, Sohal A, Hatwal J, Sharma V, Singh C, et al. Metabolic dysfunction-associated steatotic liver disease and heart failure with preserved ejection fraction: A state-of-the-art review. World J Cardiol. 2026; 18: 111954.

[17] Deng L, Tighiouart H, Oka T, Tuttle ML, Downey BC, Rowin EJ, et al. Association of Obesity with Kidney Function Outcomes in Heart Failure with Preserved Ejection Fraction. Kidney360. 2026;[Epub ahead of print].

[18] Pandit A, Gupta M, Arabie DA, Milton P, Elbatreek M, Goodchild T, et al. Obesity and Heart Failure With Preserved Ejection Fraction: A Clinical Nexus for Exercise Intolerance. Obesity (Silver Spring). 2026; 34: 984-96.

[19] Sotomi Y, Hikoso S, Komukai S, Sato T, Oeun B, Kitamura T, et al. Phenotyping of acute decompensated heart failure with preserved ejection fraction. Heart. 2022; 108: 1553-61.

[20] Anastasiou V, Peteinidou E, Moysidis DV, Daios S, Gogos C, Liatsos AC, et al. Multiorgan Congestion Assessment by Venous Excess Ultrasound Score in Acute Heart Failure. J Am Soc Echocardiogr. 2024; 37: 923-33.

[21] Palazzuoli A, Ruocco G, Beltrami M, Nuti R, Cleland JG. Combined use of lung ultrasound, B-type natriuretic peptide, and echocardiography for outcome prediction in patients with acute HFrEF and HFpEF. Clin Res Cardiol. 2018; 107: 586-96.

[22] Sonaglioni A, Lonati C, Scime’ V, Nicolosi GL, Bruno A, Lombardo M, et al. Supra-Normal Ejection Fraction at Hospital Admission Stratifies Mortality Risk in HFpEF Patients Aged ≥ 70 Years. J Clin Med. 2025; 14: 426.