Congestion in acute heart failure: a moving target in transition

This Editorial Comment refers to ‘Clinical profiles and prognostic impact of residual intravascular and tissue congestion in acute heart failure’, by D.C.H. Ceelen et al., https://doi.org/10.1002/ejhf.70091, published in volume 27, issue 12, 2025 of European Journal of Heart Failure. Congestion is the hallmark of acute heart failure (AHF) and the leading cause of hospitalization worldwide.1 Its management remains focused on achieving euvolaemia, usually through loop diuretics, yet full decongestion at discharge is rarely achieved.2,3 Residual congestion (RC) persists in 30%–40% of patients and is strongly associated with early readmission and death.2–4 Traditionally, congestion has been viewed as a single clinical entity—a binary condition of ‘wet’ versus ‘dry’. However, advances in pathophysiological understanding have reframed it as a multidimensional process involving distinct yet overlapping components. Notably, several adaptive mechanisms and the physiological distribution of fluids in our body (between intravascular and extravascular compartments) make the assessment of congestion very complex. Moreover, congestion is not synonymous with ‘simple’ fluid overload, as it may result from fluid redistribution and vasoconstriction, further complicating the situation (Figure 1).