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The fastest way to the heart is through the veins: towards a better understanding of congestion

Congestion is a hallmark feature of heart failure (HF) and is associated with organ dysfunction and impaired prognosis.1 As such, acquiring an adequate ‘decongestive’ state is the goal in every HF patient. However, the assessment of congestion can be challenging. The gold standard remains invasive measurement of right atrial pressures (RAP) and pulmonary capillary wedge pressures (PCWP). This involves deep venous puncture and advancing a pulmonary artery catheter through the right heart and pulmonary circulation, which may come with a risk of complications and is a relatively time consuming procedure. Furthermore, this cannot routinely be performed in every patient in whom the congestion status is questioned. Guidelines recommend to monitor pulmonary artery pressure (PAP) using a wireless haemodynamic monitoring system in symptomatic patients with HF in order to improve clinical outcomes (class IIb).2 However, most clinicians rely on signs (e.g. oedema, pulmonary rales, S3 sound, elevated jugular venous pressure) and symptoms (e.g. dyspnoea, orthopnoea) as a surrogate for invasive haemodynamic assessment. Despite their widespread use, these signs and symptoms lack specificity and sensitivity to be used as reliable measures to quantify congestion.3 Echocardiography is the most used non-invasive alternative to estimate filling pressures and quantify congestion, but this requires time, resources and expertise. Other non-invasive ultrasound measures such as lung ultrasound, internal jugular vein ultrasound, renal venous Doppler and inferior vena cava (IVC) ultrasound may be easier and faster alternatives.4 The IVC is of particular interest as measuring its diameter and collapsibility to estimate RAP is recommended during