Lung ultrasound in ambulatory adults with HFpEF: Association between pulmonary congestion and one-year outcomes

Abstract Aims Early detection of congestion among adults with heart failure and preserved ejection fraction (HFpEF) is critical to optimize therapy prior to overt decompensation, yet traditional tools are insensitive. We sought to examine the association between B-lines on lung ultrasound (LUS) in ambulatory adults with HFpEF and relate these to one-year outcomes. Methods In a prospective, multi-site observational study, using a pocket ultrasound device, 8-zone LUS was performed in outpatients with HFpEF, left ventricular ejection fraction ≥45% and NYHA class II-IV. Ultrasound videos were analyzed centrally, blinded to clinical findings and adjudicated outcomes. Results Among 415 participants (mean age 74 years, 52% women, 51% with obesity, median N-terminal pro-B-type natriuretic peptide (NT-proBNP) 744 pg/ml) B-lines ranged from 0 to 36 (median 3 [interquartile range 1, 6]). A total of 108 events occurred during follow-up (89 HF events, 19 deaths). Participants in the highest B-line tertile (>5 B-lines) had a higher risk of total HF events and all-cause death (rate ratio 2.37 [95% CI 1.33, 4.25; P=0.004]) and a first HF event or death (HR 2.68 [95% CI 1.54, 4.64; P<0.001]) during one-year follow-up. These associations persisted after adjusting for age, sex, body mass index, diabetes, atrial fibrillation/flutter and NT-proBNP (first events only). Conclusions Among ambulatory adults with HFpEF, a higher number of B-lines at baseline identified those at increased risk of both total HF events and all-cause death, and first HF event or death independent of known risk markers. LUS is a scalable, non-invasive strategy to assess congestion and prognosis in adults with HFpEF.