Beyond clinical congestion in acute heart failure: integrating lung ultrasound, venous doppler, and echocardiographic hemodynamics for imaging-guided decongestion.

Acute heart failure (AHF) is a major cause of hospitalisation worldwide and remains associated with substantial early rehospitalisation and short-term mortality. Accurate assessment of congestion remains challenging because symptoms, physical signs, body weight, and conventional biomarkers may not fully capture the severity, distribution, or persistence of haemodynamic congestion. This limitation contributes to incomplete decongestion and may partly explain recurrent decompensation after discharge. In this review, we examine the complementary roles of three point-of-care ultrasound modalities in residual congestion assessment: lung ultrasound for pulmonary congestion, venous Doppler/VExUS for systemic venous and end-organ congestion, and focused transthoracic echocardiography for cardiac and haemodynamic profiling. We propose the ICON (Integrated Congestion-Oriented Navigation) framework as a pragmatic bedside model that translates these modalities into a three-phase acute heart failure workflow: initial assessment, inpatient monitoring, and predischarge reassessment. Within this workflow, ICON supports phenotype-based interpretation of residual congestion, including pulmonary-dominant, systemic venous/RV-dominant, mixed, cold-wet/low-output, and near-decongested profiles. Current evidence supports the prognostic value of residual congestion and suggests that ultrasound-guided strategies may improve congestion assessment, but the evidence remains heterogeneous. The ICON framework should therefore be viewed as a proposed physiology-based model requiring prospective validation before adoption as a standard-of-care pathway.