We read with great interest the scientific statement concerning the assessment of congestion in heart failure, 1 in which clinical, laboratory, radiographic, dynamic, and echocardiographic indices were evaluated. Here, some additional markers of congestion are proposed. Nocturia is a common manifestation with considerable diagnostic accuracy in congested patients with heart failure. 2Peripheral oedemas are redistributed in the supine position, increasing the renal glomerular flow. In addition, in males, prostatic gland oedema secondary to heart failure contributes to nocturia and is relieved after increasing the dose of diuretics especially in the afternoon. Pleural transudates are frequent in heart failure with pulmonary congestion. These effusions are due to interstitial pulmonary fluids, which escape through the visceral pleura, preventing the development of alveolar oedema. 4 Large pleural transudates can be detected by radiography and echocardiography. The latter is superior as it can estimate the haemodynamic consequences of raised intrapleural pressures into a normal pericardial space. 5When compressive physiology is detected, diuretics are ineffective, and large volume thoracentesis is mandatory. Reappearance of transudates after a few days is an ominous sign of persisting pulmonary congestion.Echocardiographic grading of pulmonary congestion can be completed by simple manoeuvres which modify the left ventricular preload. It is known that the E/E a ratio (E ¼ early diastolic Doppler transmitral velocity and E a ¼ early diastolic mitral annular velocity) reflects the pulmonary wedge pressure, with a value of .15 heralding haemodynamic congestion. In patients complaining of dyspnoea but displaying an inconclusive E/E a , simple lower limb elevation for a few minutes is able to increase the preload, unmasking an abnormally high E/E a and haemodynamic pulmonary congestion. The opposite happens when the patient is asked to inflate an aneroid sphygmomanometer to the index 40 mmHg, when performing a Valsalva manoeuver. 6 An abnormal E/E a ratio which drops with decreased venous return suggests the need for further doses of diuretics. A high E/E a ratio not responding to the Valsalva manoeuvre probably indicates a pressure-not volume-overloaded left ventricle. Assessing the peripheral and pulmonary congestion in patients with (or without) heart failure is a continuous challenge. We further thank Gheorgiade and co-authors for giving us the opportunity to contribute to this provocative issue.