Assessing congestion in heart failure: tools are already available, but integration is key

Congestion represents the principal clinical manifestation and hemodynamic hallmark of heart failure (HF), reflecting elevated cardiac filling pressures. It remains the leading cause of HF hospitalization and is consistently associated with adverse outcomes across all stages of the disease. Despite its major prognostic implications, the assessment of congestion remains suboptimal in both acute and chronic settings, with up to one-third of patients discharged while still fluid overloaded. This review, developed following the Critical Care Clinical Trialists (3CT) Workshop 2025, summarizes current and well-established approaches for evaluating congestion, and introduces new and emerging tools that may simplify its recognition and management while allowing for a more accurate and timely assessment. We further discuss how integrating clinical, imaging, hemodynamic, and patient-centered strategies may enable optimal congestion management and support a paradigm shift from reactive decongestion to proactive, individualized care.