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Review
. 2025 Apr 24;15(9):1083.
doi: 10.3390/diagnostics15091083.

Contemporary Perspectives on Congestion in Heart Failure: Bridging Classic Signs with Evolving Diagnostic and Therapeutic Strategies

Mihai Grigore  1   2 , Camelia Nicolae  1   2 , Andreea-Maria Grigore  1   3 , Ana-Maria Balahura  1   2 , Nicolae Păun  1   2 , Gabriela Uscoiu  1   2 , Ioana Verde  1 , Adriana-Mihaela Ilieșiu  1   2
Affiliations
Review

Contemporary Perspectives on Congestion in Heart Failure: Bridging Classic Signs with Evolving Diagnostic and Therapeutic Strategies

Mihai Grigore et al. Diagnostics (Basel). .

Abstract

Congestion represents a defining hallmark of heart failure (HF) leading to increased morbidity and mortality in HF patients. While it was traditionally viewed as a simple and uniform state of volume overload, contemporary understanding has emphasized its complexity, distinguishing between intravascular, interstitial, and tissue congestion. Congestion contributes to overt clinical manifestation of HF. However, subclinical congestion often goes undetected, increasing the risk of adverse outcomes. Residual congestion, in particular, remains a frequent and challenging issue, with its persistence at discharge being strongly linked to rehospitalization and poor prognosis. Clinical evaluation often fails to reliably identify the resolution of congestion, highlighting the need for supplementary diagnostic methods. Improvement in imaging modalities, including lung ultrasound, venous Doppler, and echocardiography, have significantly enhanced the detection of congestion. Moreover, biomarkers such as natriuretic peptides, bioactive adrenomedullin, soluble CD146, and carbohydrate antigen 125 offer valuable, complementary insights into fluid distribution and the severity of HF congestion. Therefore, a comprehensive, multimodal strategy that integrates clinical evaluation with imaging and biomarker data is crucial for optimizing the management of congestion in HF. Future approaches should prioritize personalized decongestive therapy, addressing both intravascular and tissue congestion, while aiming to preserve renal function and limit neurohormonal activation. Refinement of these strategies holds promise for improving long-term outcomes, reducing rehospitalizations, and enhancing overall patient prognosis.

Keywords: congestion; heart failure; intravascular congestion; tissue congestion.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Sequential Doppler changes in different patients with ADHF. (a,b) Portal vein Doppler in patient with systemic congestion with pulsatile flow on admission (a), and normalized flow after decongestion (b). (c,d) Intra-renal venous Doppler in another patient with systemic congestion: discontinuous flow on admission (c), normalized flow to continuous pattern at discharge (d). (e,f) Jugular vein ultrasound in patient without systemic congestion: IJV diameter is small at rest (0.10 cm) (e) and increases up to 2.5 cm during Valsalva maneuver (f).
Figure 2
Figure 2
Integrated diagnostic algorithm for assessment of congestion related to fluid compartment distribution using clinical evaluation, biomarkers, and multimodal imaging. LUS—lung ultrasound; S3—third heart sound; S4—fourth heart sound; LVEF—left ventricular ejection fraction.
Figure 3
Figure 3
Therapeutic strategy guided by congestion profile in ADHF (acute decompensated heart failure).
See this image and copyright information in PMC

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