Non-invasieve veneuze return/cardiac output-mismatch onthult 'gebufferde' staat vóór klinische hartfalen-decompensatie

AIMS: Acute heart failure (AHF) is commonly regarded as a worsening stage of chronic heart failure (CHF), yet the hemodynamic transition to decompensation remains incompletely defined. This study evaluated whether a noninvasive physiology-guided approach based on venous return (VR)-cardiac output (CO) balance can provide a framework to characterize transitional circulatory states preceding overt AHF. METHODS: A total of 193 patients with CHF, hypertensive heart disease, or AHF were analyzed. Mean circulatory filling pressure and right atrial pressure were estimated noninvasively using inferior vena cava diameter indexed to body surface area (IVC/BSA) and extracellular-to-total body water ratio (ECW/TBW), respectively. VR-CO imbalance was quantified using a composite mismatch index. RESULTS: The distribution of VR-CO mismatch demonstrated a bimodal pattern on Gaussian mixture modeling, with two components (means ± SD: 2.25 ± 0.96 and 5.25 ± 2.61). All overt AHF cases were localized within the higher-mismatch component. Intermediate states exhibited increasing mismatch while maintaining relatively preserved forward flow, consistent with buffered circulatory states. A subset of patients exhibited marked hemodynamic mismatch without clinical congestion, representing a highly buffered pre-decompensated state. CONCLUSIONS: AHF may represent a failure of circulatory compensation in which venous-return loading exceeds the capacity of forward flow. A noninvasive VR-CO framework reveals a continuum from compensated to buffered to overtly decompensated states and identifies a previously unrecognized highly buffered state preceding clinical deterioration. This physiology-guided approach may enable earlier detection of circulatory instability and provide a quantitative framework for risk stratification and therapeutic monitoring.