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The spectrum of congestion in heart failure: underlying pathophysiology and diagnostic strategies

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Abstract

Congestion is the main driver of heart failure (HF) recurrence and its relief remains the primary therapeutic target during acute management. In most studies achievement of decongestion is evaluated by clinical examination. The lack of accurately recognizing congestion, together with the incomplete understanding of its underlying pathophysiological mechanisms, may lead to a substantial discordance between de-congestion and mortality risk reduction. To avoid these concerns, a classification dividing congestion between intra vs. extravascular, has been recently purposed but it is still based on clinical signs rather than an integrated diagnostic assessment. Additionally, across several studies, congestion is evaluated at various time moments and with different diagnostic methods. Over the last decades new approaches combining ultrasonographic evaluation, invasive measurement and biomarkers have been suggested, although a universal multi-parametric diagnostic strategy is not extensively applied. The complex mechanisms and dynamic nature of fluid retention, venous capacitance, lymphatic conditions and interstitial space integrity are relevant components which contributes to create further misunderstanding. The numerous cardiac and extracardiac factors potentially involved in congestion onset and recurrence need to be addressed during the evaluation. In this paper we would gather potential approaches for early congestion detection according to HF profile, based on the assumption that hemodynamic congestion and increased cardiac pressure does not necessarily coincide with systemic fluid retention.

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Authors and Affiliations

  1. Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital, University of Siena, Siena, 53100, Italy

    Alberto Palazzuoli, Francesca Susini, Irene Carlino & Giuseppe Schirò

  2. Arrhythmia and Electrophysiology Unit, Careggi University Hospital, Florence, 50134, Italy

    Matteo Beltrami

  3. Institute of Cardiovascular Diseases “Prof. CC Iliescu”, University of Medicine, Bucharest, Romania

    Oliviana Geavlete & Ovidiu Chioncel

  4. I Veris Delli Ponti Hospital, ASL Lecce, Scorrano, Lecce, Italy

    Gaetano Ruocco

  5. Department of Cardiology, Tokyo Medical University, Tokyo, Japan

    Masatake Kobayashi

  6. Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA

    Andrew P Ambrosy

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  1. Alberto Palazzuoli
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All authors should have made substantial contributions to the manuscript as follows: OG, AA, AG the conception and design of the study; IC GS acquisition of data,;OG, MK analysis and interpretation of data, AP, MB FS writing the article; OC, GM revising it critically for important intellectual content; AA, OC final approval of the version to be submitted.

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Andrew Ambrosy is the editor in chief of the journal Alberto Palazzuoli and Ovidiu Chioncel are associate editors.

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Palazzuoli, A., Beltrami, M., Geavlete, O. et al. The spectrum of congestion in heart failure: underlying pathophysiology and diagnostic strategies. Heart Fail Rev 31, 67 (2026). https://doi.org/10.1007/s10741-026-10639-x

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