A constant challenge in patients with heart failure (HF) is the “vulnerable period” following discharge. Hospital discharge marks the period of greatest vulnerability, during which persistent residual congestion—often undetectable on clinical examination—set patients on a path toward early readmission or even death. Traditionally, we have relied on clinical evaluation. However, it is not always sufficient and often proves misleading, as subjective decongestion does not always reflect true tissue decongestion.
This is where congestion assessment using complementary imaging tools, such as cardiopulmonary ultrasound, is no longer merely a technological option but has become a clinical necessity. While echocardiography provides information on left ventricular filling pressures, right ventricular function, and inferior vena cava dynamics, pulmonary ultrasound offers a direct view of the pulmonary parenchyma. By quantifying B-lines, it is possible to objectively determine the extent of interstitial edema long before it becomes clinically apparent.
In this regard, some authors highlight the importance of realtime imaging assessment. Platz et al. demonstrated that residual congestion detected by pulmonary ultrasound is associated with worse short- and longterm outcomes in patients hospitalized for heart failure, underscoring the importance of pulmonary ultrasound. (1) Similarly, the PROFUND-IC registry reported by Pérez-Herrero et al. highlighted the prognostic value of pulmonary ultrasound and inferior vena cava assessment in elderly patients with acute heart failure (AHF). (2)
The recent study by Iroulart et al. is an ambitious study involving elderly, typically frail population hospitalized for “pure” AHF, after excluding secondary causes of HF. The authors evaluated the prognostic value of a cardiopulmonary ultrasound protocol before hospital discharge. Notably, the B-line count at discharge was the only variable that independently predicted readmission or death at 180 days. A thresh-old of seven B-lines doubled the risk of adverse events, with a specificity of 86%. Other echocardiographic findings, including the septal and lateral E/e’ ratios, inferior vena cava dilation, and pulmonary systolic pressure, were associated with the endpoint in the univariate analysis, whereas ejection fraction and left atrial volume were not. (3)
The study focuses on the time of hospital discharge, a critical stage in clinical decisionmaking, when risk stratification becomes particularly valuable. These findings compel us to reconsider our discharge criteria and what constitutes therapeutic “success” in patients with AHF. Relying solely on clinical criteria while ignoring persistently elevated ultrasound markers of congestion is equivalent to sending patients home with subclinical decompensation. Cardiopulmonary ultrasound should not be regarded as an isolated test, but rather as a cornerstone for guiding realtime diuretic titration, allowing therapy to be individualized to achieve truly safe decongestion.