The Art and Science of Congestion Diagnosis and Management in Heart Failure - Editorial

Sep 30, 2026

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Heart failure imposes substantial global clinical burden, with congestion positioned as both the driver of acute decompensation and a central therapeutic target. This editorial synthesizes insights from four complementary papers spanning congestion pathophysiology, biomarkers, device-based strategies, and the problem of residual congestion, contextualizing findings within contemporary European Society of Cardiology guidance and recent trial evidence. Congestion is presented as a complex, multifaceted process requiring nuanced, multimodal assessment and treatment rather than simplistic interpretation as excess water.

LanguageEnglish

CategoryHealthcare

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Pages3

Reading Time8 min

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Diagnosis and Management in Heart Failure

Congestion as a central clinical process

Pathophysiology and phenotypes of congestion in HF

Biomarkers for congestion

EDITORIAL Diagnosis The Art and Science of Congestion Diagnosis and Management in Heart Failure Josip Andelo Borovac 1,2 and Dino Miric 1,2 Division of Interventional Cardiology and Ischemic Heart Disease, Department of Cardiovascular Diseases, University Hospital of Split (KBC Split), Split, Croatia University of Split School of Medicine (USSM), Split, Croatia | Keywords
Congestion, heart failure, intravascular, extravascular, biomarkers, pathophysiology, devices | | --- | | Received: 19 November 2025 Accepted: 26 November 2025 Citation: Cardiac Failure Review 2025;11:e35 . DOI: [https://doi.org/10.15420/cfr.2025.53](https://doi.org/10.15420/cfr.2025.53)
[Disclosure:](Disclosure: JAB is on the Cardiac Failure Review editorial board)[ JAB is on the Cardiac Failure Review editorial board](Disclosure: JAB is on the Cardiac Failure Review editorial board); this did not influence acceptance. DM has no conflicts of interest to declare.
Correspondence: Josip A Borovac, Division of Interventional Cardiology and Ischemic Heart Disease, Department of Cardiovascular Diseases, University Hospital of Split
(KBC Split), Soltanska 1, 21000 Split, Croatia. E: [jborovac@mefst.hr](jborovac@mefst.hr) | | Copyright: © The Author(s) 2025. This work is open access and is licensed under CC BY-NC 4.0. Users may copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly. | Heart failure (HF) is a significant clinical burden contributing to many deaths and hospitalisations worldwide, and congestion lies at its core, both as the chief culprit of acute decompensation events and a key therapeutic target.1,2 In this Cardiac Failure Review special collection, four complementary, state-of-the-art papers explore congestion from unique perspectives: pathophysiology, biomarkers, device-based strategies and the challenge of residual congestion. This editorial synthesises insights gained from these papers and places them in the context of contemporary clinical practice, including the latest European Society of Cardiology (ESC) guidelines on HF and the ESC’s 2023 focused update, as well as recent trial findings.3,4 The central message we hope to convey is that congestion is not merely a phenomenon of excess water in a patient with HF, but instead is a complex, multifaceted process that requires nuanced assessment and a multimodal diagnostic and therapeutic approach.5 Pathophysiology and Phenotypes of Congestion in HF Traditionally, clinicians have perceived congestion in HF as simple fluid overload. In their review, Kumric et al. challenge this oversimplification, providing mechanistic insights into how acute HF decompensation can arise from internal volume redistribution without a net gain in total body water.6 They differentiate two overlapping congestion phenotypes: intravascular congestion (elevated cardiac filling pressures due to central shifting of venous blood) versus extravascular congestion (excess fluid sequestered in interstitial tissues) . In clinical practice, these phenotypes often coexist, and patients may transition between them during the clinical course. Distinguishing between these two types of congestion is important because each may require different therapeutic strategies. For example, sympathetic activation and venous constriction can acutely redistribute venous blood and raise filling pressures (intravascular congestion) even if weight gain is minimal. Conversely, sodium retention by the kidneys and fluid accumulation over weeks lead to expanded interstitial volume (extravascular congestion) with clinical manifestations of oedema. Kumric and colleagues emphasise that the severity of congestion is not linearly related to left ventricular systolic function. Notably, some patients with only mild cardiac dysfunction are profoundly congested, while others with significantly reduced left ventricular ejection fraction (LVEF) and frank HF, such as those

FAQs

Why is congestion considered central in heart failure management?

Congestion underlies acute decompensation events and represents a key therapeutic target. The editorial emphasizes that it drives major clinical burden and requires careful assessment.

What are intravascular and extravascular congestion phenotypes?

Intravascular congestion reflects elevated cardiac filling pressures from central venous blood shifting, while extravascular congestion reflects excess interstitial fluid from sodium and fluid retention. Patients may transition between these phenotypes over time.

Why can established symptoms and physical signs be insufficient to assess congestion?

Physical findings and patient-reported dyspnoea show limited sensitivity and specificity because signs may correspond to different physiological compartments. Patients can present with one type of finding without the other, so additional tools are needed.

Sep 30, 2026

Uploaded by Mimi