Arq Bras Cardiol: Imagem cardiovasc. 2025; 38(2): e20250039

New Tools for Optimizing HF Management: The Role of POCUS in the Office

Luiz Claudio

Danzmann

, Elisa

Kalil

, Soraya Abunader

Kalil

DOI: 10.36660/abcimg.20250039i

A Reflection on Clinical and Subclinical Circulatory Congestion

The management of heart failure (HF) has improved over the past 20 years, mainly due to advances in diagnostic methods and circulatory decongestion strategies. Several management strategies have demonstrated efficacy in reducing symptoms, lowering rates of HF decompensation events, decreasing mortality indices, and improving surrogate markers of clinical events, such as left ventricular ejection fraction (LVEF). In HF management, the need for detecting and monitoring circulatory congestion is justified by its strong association with neurohormonal activation and systemic inflammation, which contribute to the progressive worsening of HF and, consequently, a higher incidence of clinical events.

But what is the evidence supporting decongestion strategies with diuretics in reducing hard outcomes? In the outpatient setting, the STRONG-HF clinical trial is a good example. Comparing intensive optimization strategy versus usual HF treatment after hospital discharge, the study demonstrated that the group with more frequent visits and more intensive management achieved an absolute risk reduction of 8.1% (15.2% vs. 23.3%, P=0.0021) in the combined outcome of all-cause mortality and/or HF hospitalization within 180 days of follow-up. The statistically significant reduction in clinical signs of congestion, along with a 27% decrease in natriuretic peptide (NP) levels after three months, provided proof of concept for the relationship between decongestion and clinical benefit. This evidence reinforces the need to detect subclinical congestion, especially during the vulnerable phase of HF, which occurs between one and three months after an HF hospitalization, a period in which most potentially preventable events take place.

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