Inferior Vena Cava Ultrasound for Decongestion Assessment in Acute Heart Failure: Systematic Review

Residual congestion at discharge in acute heart failure (AHF) is a primary driver of readmission and mortality. Inferior vena cava (IVC) ultrasound provides a noninvasive bedside assessment of volume status, yet its clinical impact on guiding therapy remains underdefined. This systematic review evaluated the efficacy of IVC ultrasound-guided therapy compared to standard clinical assessment in AHF decongestion.

Following PRISMA guidelines (PROSPERO: CRD420251171323), a systematic search was conducted across PubMed, EMBASE, and other major databases through October 2025. We included randomized controlled trials (RCTs) and nonrandomized studies focusing on IVC-guided management in adults with AHF. Outcomes included congestion markers, NT-proBNP levels, hospitalization duration, and mortality.

Four studies involving 629 patients met the inclusion criteria. Most studies showed improved decongestion with IVC ultrasound guidance, evidenced by lower residual congestion and improved IVC metrics (diameter/collapsibility). While NT-proBNP levels decreased in all cohorts, between-group differences were not statistically significant. Clinical outcomes improved in 50% of studies, showing shorter hospital stays and reduced mortality. Notably, one trial reported a significant mortality benefit (3.3% vs. 33.3%; p = 0.003). Adverse events were either similar or significantly fewer (p < 0.05) in the ultrasound-guided groups.

IVC ultrasound is an effective bedside tool for individualized volume management in AHF, potentially enhancing treatment precision and clinical outcomes. While current evidence is promising, larger multicenter trials are necessary to standardize its implementation in routine heart failure care.