Congestion Assessment in Heart Failure Management

Congestion assessment is central to the management of heart failure, as fluid overload in the pulmonary and systemic circulation drives symptoms, readmission and mortality. Clinical evaluation begins with history and physical signs such as dyspnoea, crackles, elevated jugular venous pressure and peripheral oedema, but these may lack sensitivity and reproducibility. Chest radiography offers semiquantitative indices of pulmonary venous congestion, interstitial thickening and alveolar oedema. Natriuretic peptides provide biochemical markers of elevated intracardiac filling pressures yet are influenced by renal function and body habitus. Echocardiography yields indirect estimates of left ventricular filling pressures and valvular regurgitation, while cardiovascular magnetic resonance enables quantitative lung water measurement in research settings. Point-of-care lung ultrasound detects B-lines, real-time artefacts that reflect interstitial fluid and correlate with haemodynamic status. Emerging approaches include automated analysis of radiographs using deep learning to estimate pulmonary artery wedge pressure. Accurate, reproducible congestion assessment guides diuretic dosing, risk stratification and timing of discharge, aiming to reduce hospitalisation rates and improve long-term outcomes. Integration of multimodal data into decongestion strategies represents a global priority in personalised heart failure care.

Research from Nature Portfolio

Recent studies have demonstrated the prognostic value of cardiovascular magnetic resonance-derived lung water quantification in patients with reduced ejection fraction. A simplified approach using a standard HASTE sequence enables rapid calculation of lung water density as the lung-to-liver signal ratio multiplied by a scaling factor. Elevated values above the established normal threshold identified patients at greater risk of heart failure hospitalisation and all-cause mortality, independent of conventional clinical and biochemical markers. This method proved highly reproducible across observers and could be incorporated into routine CMR protocols to enhance risk stratification and guide tailored decongestion strategies.

Congestion Assessment in Heart Failure Management publication trend

The graph below shows the total number of articles in congestion assessment in heart failure management across all publications each year (not limited to Nature Index journals).

Technical terms

Pulmonary congestion: Accumulation of excess fluid within the pulmonary interstitium and alveolar spaces due to elevated cardiac filling pressures.
B-lines: Vertical reverberation artefacts on lung ultrasound representing interstitial fluid in the lung parenchyma.
Lung water density: Quantitative measure of fluid content in lung tissue derived from signal intensity ratios on cardiovascular magnetic resonance.
Congestion Score Index: Semiquantitative grading of pulmonary congestion on chest radiography based on vascular redistribution, Kerley lines and alveolar oedema.
Pulmonary artery wedge pressure: Indirect measurement of left atrial pressure obtained during right heart catheterisation, reflecting left-sided filling pressures.
Cardiovascular magnetic resonance (CMR): Imaging modality using magnetic fields and radiofrequency pulses to produce detailed anatomical and quantitative assessments of cardiac and adjacent structures.

References

1. Use of Imaging-guided Decongestion for Reducing Heart Failure Readmission and Death in High-risk Patients: A Multi-site Randomized Trial of a Nurse-led Strategy at the Point of Care. Journal of Cardiac Failure (2023).
2. Quantification of lung water in heart failure using cardiovascular magnetic resonance imaging. Journal of Cardiovascular Magnetic Resonance (2019).
3. Measuring lung water adds prognostic value in heart failure patients undergoing cardiac magnetic resonance. Scientific Reports (2021).
4. Diagnostic performance of congestion score index evaluated from chest radiography for acute heart failure in the emergency department: A retrospective analysis from the PARADISE cohort. PLOS Medicine (2020).
5. Clinical, Laboratory and Lung Ultrasound Assessment of Congestion in Patients with Acute Heart Failure. Journal of Clinical Medicine (2022).
6. Quantitative estimation of pulmonary artery wedge pressure from chest radiographs by a regression convolutional neural network. Heart and Vessels (2022).