Intrarenal venous flow improvement after vericiguat in worsening HFrEF: A prospective VExUS-based study

In patients with heart failure with reduced ejection fraction (HFrEF) and recent worsening despite guideline-directed medical therapy (GDMT), vericiguat reduces adverse cardiovascular events. However, its effects on systemic venous congestion assessed by the Venous Excess Ultrasound (VExUS) protocol remain unclear. We aimed to evaluate changes in VExUS parameters after vericiguat initiation and identify predictors of intrarenal venous flow (IRVF) normalization.

In this single-center prospective observational study, consecutive patients eligible for vericiguat were enrolled. Clinical, laboratory, and VExUS assessments, including inferior vena cava, lung B-lines, jugular venous distension, hepatic vein Doppler flow, and IRVF, were performed at baseline and after 6 months. Renal resistive index (RRI) was also measured.

42 patients (mean age 72.5 ± 9.7 years; 81.0% male) were included. At follow-up, IRVF was the only VExUS parameter showing significant improvement, with an increase in continuous patterns (p = 0.021). In multivariable analysis, vericiguat therapy and higher estimated glomerular filtration rate (eGFR) were independently associated with continuous IRVF (p < 0.001), whereas RRI ≥0.70 and abnormal hepatic venous flow predicted discontinuous IRVF.

IRVF was the most sensitive VExUS parameter and improved after vericiguat in worsening HFrEF. These findings suggest a potential beneficial effect of vericiguat on renal venous congestion and cardiorenal hemodynamic.