Trusted medical expertise in seconds.

Access 1,000+ clinical and preclinical articles. Find answers fast with the high-powered search feature and clinical tools.

Try free for 5 days
Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer.

Acute heart failure

Last updated: November 22, 2021

Contributor disclosurestoggle arrow icon

None of the individuals in control of the content for this article (a continuing medical education activity) reported relevant financial relationships with commercial interests.

The full conflict of interest (COI) policy for our continuing medical education (CME) program can be found within “AMBOSS CME information and policies.”

Acute heart failure is the rapid onset or worsening of heart failure symptoms, and it is a common cause of hospitalization in older patients. Multiple triggers can cause an acute decompensation of preexisting heart failure (ADHF) but the condition may also occur suddenly in patients with no previous history of the condition (de novo heart failure). Diagnosis is based on typical clinical features (e.g., dyspnea), laboratory findings (e.g., elevated BNP), and imaging findings (e.g., pulmonary edema). Management is often challenging because of comorbidities; most patients require admission for treatment with IV diuretics, vasodilators, adjustment of their chronic heart failure medications, respiratory support, and careful monitoring.

Etiology of acute heart failure
Type of acute heart failure Underlying etiology [1][3]
De novo heart failure

Clinical features of acute heart failure are commonly classified according to perfusion and the presence of congestion at rest. [1][2][5]

Classification of acute heart failure [5][6]
No evidence of congestion (∼5% of patients) Evidence of congestion (∼95% of patients)
Adequate perfusion
  • Warm and dry
  • Warm and wet
  • Cold and dry
  • Cold and wet

Diagnosis of acute heart failure consists of a combination of clinical features, laboratory markers (e.g., BNP), and supportive imaging findings. It is important to evaluate for the underlying cause and rule out life-threatening comorbidities (e.g., ACS).

Laboratory studies [7]

  • BNP (or NT-proBNP): Measure in every patient suspected of having acute heart failure.
    • Should always be interpreted in comparison to the patient's baseline and in the context of history, examination, and imaging.
    • High diagnostic utility in patients with unclear diagnosis [7]
Natriuretic peptide levels in the diagnosis of heart failure [8][6][9]
Heart failure unlikely Heart failure likely
BNP (in pg/mL)

< 100 [8]

> 400 [9]

NT-proBNP (in pg/mL)

< 300 [10]

> 900

Measuring BNP (or NT-proBNP) is especially helpful in patients with unclear diagnosis. BNP has a high diagnostic value when combined with physical examination and imaging.


Indicated in all patients to exclude ACS. Findings are variable and may include: [5][6]

Initial imaging

All patients with suspected acute heart failure should have a CXR and echocardiography performed.

CXR [5][14]

ABCDE: Alveolar edema (bat wings), Kerley B lines (interstitial edema), Cardiomegaly, Dilated prominent pulmonary vessels, and Effusions

Transthoracic echocardiogram (TTE) [5][17]

POCUS in acute heart failure

Advanced imaging

If more detailed information about myocardial viability and/or perfusion is needed (e.g., procedural planning, myocardial ischemia is suspected), further imaging modalities may be necessary after the patient is stabilized. Both MRI and CT require the patient to lie flat for sustained periods and are less accurate at higher heart rates.

See also “Differential diagnoses of dyspnea.”

The differential diagnoses listed here are not exhaustive.

Approach [6]

Hemodynamically unstable patients (i.e., cardiogenic shock) [6][25]

See “Management of cardiogenic shock” for details on therapeutic targets and monitoring. See “Treatment of refractory AHF” for management of patients with cardiogenic shock refractory to the following interventions.

Avoid inotropes in patients with left ventricular outflow tract obstruction (e.g., hypertrophic cardiomyopathy, aortic stenosis). [28]

Hemodynamically stable patients

Management of hemodynamically stable patients with acute heart failure [6]
Dry and warm
  • Optimize oral therapy.
Wet and warm
Wet and cold (if SBP is > 90 mm Hg)

Respiratory support in acute heart failure [6]

EPAP and/or PEEP should be used with caution in patients with hemodynamic compromise.

Diuretic therapy in acute heart failure

Vasodilator therapy in acute heart failure [5][6]

Avoid the use of vasodilators in patients with acute heart failure and hypotension.

Treatment of refractory acute heart failure

To remember the management of ADHF, think of “LMNOP”: Loop diuretics (furosemide), Modify medications, Nitrates, Oxygen if hypoxic, Position (with elevated upper body). [6][26]

Ongoing hospital management

Supportive care

Optimization of medical therapy for chronic heart failure [2][5][6]

For patients not previously on beta blockers, use cautiously and only once the patient has been stabilized.

Management of common comorbidities and complications

Monitoring [2][5]

All patients

Hemodynamically unstable patients (i.e., cardiogenic shock)

Hemodynamically stable patients

Ongoing management

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

  1. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016; 37 (27): p.2129-2200. doi: 10.1093/eurheartj/ehw128 . | Open in Read by QxMD
  2. Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017; 136 (16). doi: 10.1161/cir.0000000000000525 . | Open in Read by QxMD
  3. Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med. 2018; 55 (5): p.635-646. doi: 10.1016/j.jemermed.2018.08.002 . | Open in Read by QxMD
  4. Pollard S, Edwin SB, Alaniz C. Vasopressor and Inotropic Management Of Patients With Septic Shock.. P T. 2015; 40 (7): p.438-50.
  5. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2013; 62 (16): p.e147-e239. doi: 10.1016/j.jacc.2013.05.019 . | Open in Read by QxMD
  6. Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy. Circulation. 2011; 124 (24). doi: 10.1161/cir.0b013e318223e2bd . | Open in Read by QxMD
  7. Martin-Du Pan RC, Benoit R, Girardier L. The role of body position and gravity in the symptoms and treatment of various medical diseases.. Swiss Med Wkly. 2004; 134 (37-38): p.543-51.
  8. Kang MG, Kim K, Ju S, et al. Clinical efficacy of high-flow oxygen therapy through nasal cannula in patients with acute heart failure. J Thorac Dis. 2019; 11 (2): p.410-417. doi: 10.21037/jtd.2019.01.51 . | Open in Read by QxMD
  9. Zhao H, Wang H, Sun F, Lyu S, An Y. High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis. Critical Care. 2017; 21 (1): p.184. doi: 10.1186/s13054-017-1760-8 . | Open in Read by QxMD
  10. Rochwerg B, Granton D, Wang DX, et al. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med. 2019; 45 : p.563–572. doi: 10.1007/s00134-019-05590-5 . | Open in Read by QxMD
  11. Ferreyro BL, Angriman F, Munshi L, et al. Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory Failure. JAMA. 2020 . doi: 10.1001/jama.2020.9524 . | Open in Read by QxMD
  12. Masip J. Noninvasive Ventilation in Acute Heart Failure. Curr Heart Fail Rep. 2019; 16 (4): p.89-97. doi: 10.1007/s11897-019-00429-y . | Open in Read by QxMD
  13. Felker GM, Lee KL, Bull DA, et al. Diuretic Strategies in Patients with Acute Decompensated Heart Failure. N Engl J Med. 2011; 364 (9): p.797-805. doi: 10.1056/nejmoa1005419 . | Open in Read by QxMD
  14. Mullens W, Damman K, Harjola V-P, et al. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2019; 21 (2): p.137-155. doi: 10.1002/ejhf.1369 . | Open in Read by QxMD
  15. Oh SW, Han SY. Loop Diuretics in Clinical Practice. Electrolyte Blood Press. 2015; 13 (1): p.17-21. doi: 10.5049/EBP.2015.13.1.17 . | Open in Read by QxMD
  16. Eisen H. Heart Failure. Springer-Verlag London ; 2017
  17. Whelton, PK, Carey, RM et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension. 2017; 71 (6): p.e13–e115. doi: 10.1161/hyp.0000000000000065 . | Open in Read by QxMD
  18. Jeremias A. Cardiac Intensive Care. Elsevier Health Sciences ; 2010
  19. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63 (22): p.e57-185. doi: 10.1016/j.jacc.2014.02.536 . | Open in Read by QxMD
  20. Chakaramakkil MJ, Sivathasan C. ECMO and Short-term Support for Cardiogenic Shock in Heart Failure. Curr Cardiol Rep. 2018; 20 (10). doi: 10.1007/s11886-018-1041-4 . | Open in Read by QxMD
  21. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Advances. 2018; 2 (22): p.3198-3225. doi: 10.1182/bloodadvances.2018022954 . | Open in Read by QxMD
  22. Teerlink J, Alburikan K, Metra M, Rodgers J. Acute Decompensated Heart Failure Update. Curr Cardiol Rev. 2014; 11 (1): p.53-62. doi: 10.2174/1573403x09666131117174414 . | Open in Read by QxMD
  23. DiMarco JP. Atrial Fibrillation and Acute Decompensated Heart Failure. Circulation: Heart Failure. 2009; 2 (1): p.72-73. doi: 10.1161/circheartfailure.108.830349 . | Open in Read by QxMD
  24. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016; 133 (14): p.e506–e574. doi: 10.1161/cir.0000000000000311 . | Open in Read by QxMD
  25. Rangaswami J, Bhalla V, Blair JEA, et al. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation. 2019; 139 (16). doi: 10.1161/cir.0000000000000664 . | Open in Read by QxMD
  26. Pufulete M, Maishman R, Dabner L, et al. B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data. Syst Rev. 2018; 7 (1). doi: 10.1186/s13643-018-0776-8 . | Open in Read by QxMD
  27. Öhman J, Harjola VP, Karjalainen P, Lassus J. Focused echocardiography and lung ultrasound protocol for guiding treatment in acute heart failure.. ESC Heart Fail. 2018; 5 (1): p.120-128. doi: 10.1002/ehf2.12208 . | Open in Read by QxMD
  28. Kaplan JA. Kaplan's Cardiac Anesthesia E-Book. Elsevier Health Sciences ; 2016
  29. Viau DM, Sala-Mercado JA, Spranger MD, O’Leary DS, Levy PD. The pathophysiology of hypertensive acute heart failure. Heart. 2015; 101 (23): p.1861-1867. doi: 10.1136/heartjnl-2015-307461 . | Open in Read by QxMD
  30. Kurmani S, Squire I. Acute Heart Failure: Definition, Classification and Epidemiology. Curr Heart Fail Rep. 2017; 14 (5): p.385-392. doi: 10.1007/s11897-017-0351-y . | Open in Read by QxMD
  31. Page RL, O’Bryant CL, Cheng D, et al. Drugs That May Cause or Exacerbate Heart Failure. Circulation. 2016; 134 (6). doi: 10.1161/cir.0000000000000426 . | Open in Read by QxMD
  32. Sureka B, Bansal K, Arora A. Pulmonary edema − cardiogenic or noncardiogenic?. J of Family Med and Prim Care. 2015; 4 (2): p.290. doi: 10.4103/2249-4863.154684 . | Open in Read by QxMD
  33. Jardins TD, Burton GG. Clinical Manifestations & Assessment of Respiratory Disease E-Book. Elsevier Health Sciences ; 2019
  34. Weintraub NL, Collins SP, Pang PS, et al. Acute Heart Failure Syndromes: Emergency Department Presentation, Treatment, and Disposition: Current Approaches and Future Aims. Circulation. 2010; 122 (19): p.1975-1996. doi: 10.1161/cir.0b013e3181f9a223 . | Open in Read by QxMD
  35. Chow SL, Maisel AS, Anand I, et al. Role of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association. Circulation. 2017; 135 (22). doi: 10.1161/cir.0000000000000490 . | Open in Read by QxMD
  36. Maisel A, Mueller C, Adams K, et al. State of the art: Using natriuretic peptide levels in clinical practice. Eur J Heart Fail. 2008; 10 (9): p.824-839. doi: 10.1016/j.ejheart.2008.07.014 . | Open in Read by QxMD
  37. Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients. Eur Heart J. 2005; 27 (3): p.330-337. doi: 10.1093/eurheartj/ehi631 . | Open in Read by QxMD
  38. Grote Beverborg N, van Veldhuisen DJ, van der Meer P. Anemia in Heart Failure. JACC Heart Fail. 2018; 6 (3): p.201-208. doi: 10.1016/j.jchf.2017.08.023 . | Open in Read by QxMD
  39. Madias JE. Low QRS voltage and its causes. J Electrocardiol. 2008; 41 (6): p.498-500. doi: 10.1016/j.jelectrocard.2008.06.021 . | Open in Read by QxMD
  40. Gouda P, Brown P, Rowe BH, McAlister FA, Ezekowitz JA. Insights into the importance of the electrocardiogram in patients with acute heart failure. Eur J Heart Fail. 2016; 18 (8): p.1032-1040. doi: 10.1002/ejhf.561 . | Open in Read by QxMD
  41. Mueller-Lenke N. Use of chest radiography in the emergency diagnosis of acute congestive heart failure. Heart. 2006; 92 (5): p.695-696. doi: 10.1136/hrt.2005.074583 . | Open in Read by QxMD
  42. Natanzon A, Kronzon I. Pericardial and Pleural Effusions in Congestive Heart Failure—Anatomical, Pathophysiologic, and Clinical Considerations. Am J Med Sci. 2009; 338 (3): p.211-216. doi: 10.1097/maj.0b013e3181a3936f . | Open in Read by QxMD
  43. Broder J. Diagnostic Imaging for the Emergency Physician E-Book. Elsevier Health Sciences ; 2011
  44. Papadimitriou L, Georgiopoulou VV, Kort S, Butler J, Kalogeropoulos AP. Echocardiography in Acute Heart Failure: Current Perspectives. J Card Fail. 2016; 22 (1): p.82-94. doi: 10.1016/j.cardfail.2015.08.001 . | Open in Read by QxMD
  45. Čelutkienė J, Lainscak M, Anderson L, et al. Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure. 2020; 22 (2): p.181-195. doi: 10.1002/ejhf.1678 . | Open in Read by QxMD
  46. Bishu K, Redfield MM. Acute Heart Failure with Preserved Ejection Fraction: Unique Patient Characteristics and Targets for Therapy. Curr Heart Fail Rep. 2013; 10 (3): p.190-197. doi: 10.1007/s11897-013-0149-5 . | Open in Read by QxMD
  47. Pivetta E, Goffi A, Nazerian P, et al. Lung ultrasound integrated with clinical assessment for the diagnosis of acute decompensated heart failure in the emergency department: a randomized controlled trial. Eur J Heart Fail. 2019; 21 (6): p.754-766. doi: 10.1002/ejhf.1379 . | Open in Read by QxMD
  48. Russell FM, Ehrman RR, Cosby K, et al. Diagnosing Acute Heart Failure in Patients With Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol. Acad Emerg Med. 2015; 22 (2): p.182-191. doi: 10.1111/acem.12570 . | Open in Read by QxMD
  49. Martindale JL, Wakai A, Collins SP, et al. Diagnosing Acute Heart Failure in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016; 23 (3): p.223-242. doi: 10.1111/acem.12878 . | Open in Read by QxMD
  50. Gaskamp M, Blubaugh M, McCarthy LH, Scheid DC. Can Bedside Ultrasound Inferior Vena Cava Measurements Accurately Diagnose Congestive Heart Failure in the Emergency Department? A Clin-IQ.. J Patient Cent Res Rev. 2016; 3 (4): p.230-234.
  51. Russell FM, Rutz M, Pang PS. Focused Ultrasound in the Emergency Department for Patients with Acute Heart Failure.. Card Fail Rev. 2015; 1 (2): p.83-86. doi: 10.15420/cfr.2015.1.2.83 . | Open in Read by QxMD
  52. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017; 136 (6). doi: 10.1161/cir.0000000000000509 . | Open in Read by QxMD
  53. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013; 62 (16): p.1495-1539. doi: 10.1016/j.jacc.2013.05.020 . | Open in Read by QxMD
  54. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014; 64 (21): p.e1-e76. doi: 10.1016/j.jacc.2014.03.022 . | Open in Read by QxMD
  55. Ferri FF. Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1 (Ferri's Medical Solutions). Elsevier ; 2017 : p. 1779
  56. Yoo B-S. Clinical Significance of B-type Natriuretic Peptide in Heart Failure. J Lifestyle Med. 2014; 4 (1): p.34-38. doi: 10.15280/jlm.2014.4.1.34 . | Open in Read by QxMD
  57. Feenstra J, Grobbee DE, Remme WJ, Stricker BHC. Drug-induced heart failure. J Am Coll Cardiol. 1999; 33 (5): p.1152-1162. doi: 10.1016/s0735-1097(99)00006-6 . | Open in Read by QxMD
  58. Pan AM, Stiell IG, Clement CM, Acheson J, Aaron SD. Feasibility of a structured 3-minute walk test as a clinical decision tool for patients presenting to the emergency department with acute dyspnoea. Emergency Medicine Journal. 2009; 26 (4): p.278-282. doi: 10.1136/emj.2008.059774 . | Open in Read by QxMD
  59. Kuhn B, Bradley L, Dempsey T, Puro A, Adams J. Management of Mechanical Ventilation in Decompensated Heart Failure. J Cardiovasc Dev Dis. 2016; 3 (4): p.33. doi: 10.3390/jcdd3040033 . | Open in Read by QxMD
  60. Jobs A, Simon R, de Waha S, et al. Pneumonia and inflammation in acute decompensated heart failure: a registry-based analysis of 1939 patients. Eur Heart J Acute Cardiovasc Care. 2017; 7 (4): p.362-370. doi: 10.1177/2048872617700874 . | Open in Read by QxMD
  61. Čelutkienė J, Balčiūnas M, Kablučko D, Vaitkevičiūtė L, Blaščiuk J, Danila E. Challenges of Treating Acute Heart Failure in Patients with Chronic Obstructive Pulmonary Disease.. Card Fail Rev. 2017; 3 (1): p.56-61. doi: 10.15420/cfr.2016:23:2 . | Open in Read by QxMD
  62. Dunlap ME, Hauptman PJ, Amin AN, et al. Current Management of Hyponatremia in Acute Heart Failure: A Report From the Hyponatremia Registry for Patients With Euvolemic and Hypervolemic Hyponatremia (HN Registry). J Am Heart Assoc. 2017; 6 (8). doi: 10.1161/jaha.116.005261 . | Open in Read by QxMD
  63. Lee KK, Yang J, Hernandez AF, Steimle AE, Go AS. Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization.. Med Care. 2016; 54 (4): p.365-72. doi: 10.1097/MLR.0000000000000492 . | Open in Read by QxMD
  64. Spicuzza L, Schisano M. High-flow nasal cannula oxygen therapy as an emerging option for respiratory failure: the present and the future. Therapeutic Advances in Chronic Disease. 2020; 11 : p.204062232092010. doi: 10.1177/2040622320920106 . | Open in Read by QxMD
  65. Mauri T, Wang Y-M, Dalla Corte F, Corcione N, Spinelli E, Pesenti A. Nasal high flow: physiology, efficacy and safety in the acute care setting, a narrative review. Open Access Emergency Medicine. 2019; Volume 11 : p.109-120. doi: 10.2147/oaem.s180197 . | Open in Read by QxMD
  66. Papazian L, Corley A, Hess D, et al. Use of high-flow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med. 2016; 42 (9): p.1336-1349. doi: 10.1007/s00134-016-4277-8 . | Open in Read by QxMD
  67. Cole RT, Kalogeropoulos AP, Georgiopoulou VV, et al. Hydralazine and Isosorbide Dinitrate in Heart Failure. Circulation. 2011; 123 (21): p.2414-2422. doi: 10.1161/circulationaha.110.012781 . | Open in Read by QxMD
  68. Taylor AL, Ziesche S, Yancy C, et al. Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure. N Engl J Med. 2004; 351 (20): p.2049-2057. doi: 10.1056/nejmoa042934 . | Open in Read by QxMD
  69. Ziaeian B, Fonarow GC, Heidenreich PA. Clinical Effectiveness of Hydralazine–Isosorbide Dinitrate in African-American Patients With Heart Failure. JACC Heart Fail. 2017; 5 (9): p.632-639. doi: 10.1016/j.jchf.2017.04.008 . | Open in Read by QxMD