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This review synthesizes contemporary evidence across the spectrum of congestion in acute heart failure, clinical, subclinical, and residual, and summarizes the strengths and limitations of clinical examination, natriuretic peptides and other laboratory markers, and imaging modalities (chest radiography, lung ultrasound, echocardiographic Doppler indices, inferior vena cava assessment) for identifying congestion and tracking response to therapy. We highlight persistent residual congestion as a common discharge phenotype consistently linked to adverse outcomes, while emphasizing why prior biomarker\u2010 and imaging\u2010guided strategies have not yet produced definitive outcome improvements. Finally, we propose a profile\u2010based approach that integrates residual congestion (the manifestation of decongestive effort at a given time point) with diuretic resistance (the underlying cardio\u2010renal\/sodium\u2010handling substrate) to better identify who will respond, who requires early escalation, and how to personalize decongestive intensity and postdischarge surveillance.<\/jats:p>","DOI":"10.1161\/jaha.126.052271","type":"journal-article","created":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T14:52:31Z","timestamp":1788965551000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Overcoming Residual Congestion in Acute Heart Failure: Defining Targets and Identifying Diuretic Responders"],"prefix":"10.1161","volume":"15","author":[{"given":"Francisco B.","family":"Alexandrino","sequence":"first","affiliation":[{"name":"Cleveland Clinic","place":["Cleveland, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7663-4902","authenticated-orcid":false,"suffix":"Jr","given":"S\u00edlvio Nunes","family":"Augusto","sequence":"additional","affiliation":[{"name":"Heart Vascular and Thoracic Institute, Cleveland Clinic","place":["Cleveland, USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8335-735X","authenticated-orcid":false,"given":"W. 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