Acute heart failure

Last updated: November 28, 2023

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Summarytoggle arrow icon

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 (HF) medications, respiratory support, and careful monitoring.

Definitiontoggle arrow icon

Etiologytoggle arrow icon

Etiology of acute heart failure
Type of acute heart failure Underlying etiology [2][4]
De novo heart failure

Consider COVID-19 infection as a potential cause in both de novo heart failure and ADHF. [7]

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Clinical features of acute heart failure are commonly classified according to perfusion and the presence of congestion at rest. [2][3][6]

Classification of acute heart failure [6][8]
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

The combined presence of jugular venous distention, S3 gallop, and lung crackles/rales makes a diagnosis of acute heart failure highly likely. [9]

Assess for clinical features that are suggestive of hypoperfusion (e.g., narrow pulse pressure, cool extremities, peripheral cyanosis, altered mental status, below baseline blood pressure) to identify patients with or at risk of cardiogenic shock. [3]

Diagnosticstoggle arrow icon


Diagnosis of AHF is primarily clinical; obtain natriuretic peptide if the diagnosis is uncertain.

Laboratory studies [10][11]

  • BNP or NT-proBNP: useful for diagnostic confirmation and prognostication; can be measured serially to guide therapy [12][13]
    • 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 an unclear diagnosis [10][11]
Natriuretic peptide levels in the diagnosis of heart failure [8][11][14]
Heart failure unlikely [15] Heart failure likely [15]
BNP (pg/mL)

< 100 [14]

> 500

NT-proBNP (pg/mL)

< 300 [16]

> 1000 [11]

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

In a patient presenting with acute dyspnea, a low BNP (or NT-proBNP) makes a diagnosis of acute heart failure very unlikely.


An ECG is indicated in all patients to assess for ACS, arrhythmias, and conduction abnormalities.

Initial imaging

All patients with suspected acute heart failure should have a chest x-ray and echocardiography performed.

Chest x-ray [6][22]

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

Transthoracic echocardiogram (TTE) [6][26]

POCUS in acute heart failure

Perform a rapid assessment with bedside echocardiography and other POCUS techniques to quickly establish the underlying cause of acute dyspnea and/or shock.

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.

Differential diagnosestoggle arrow icon

See also “Differential diagnoses of dyspnea.”

Wheezing can be heard in both acute heart failure and obstructive lung disease (e.g., asthma exacerbation, AECOPD). [35]

The differential diagnoses listed here are not exhaustive.

Managementtoggle arrow icon

Initial management [8]

  • Perform a rapid ABCDE survey to assess hemodynamic stability.
  • Identify and treat any acute underlying cause of AHF for all patients (e.g., consider PCI for patients with ACS).

Hemodynamically stable patients

To remember the management of ADHF, think of “LMNOP”: Loop diuretics (furosemide), Modify medications, Nitrates, Oxygen if hypoxic, Position (with elevated upper body). [8][36]

For patients with ACS complicated by acute heart failure, consult cardiology for consideration of urgent coronary catheterization.

Hemodynamically unstable patients [37]

Early specialist consultation (e.g., critical care, cardiology) and admission to hospital is recommended.

Patients with a wet and cold clinical presentation have a high risk of rapid deterioration and require close hemodynamic monitoring regardless of their blood pressure. [8]

If atrial fibrillation is thought to be causing hemodynamic or respiratory instability, consider immediate electric cardioversion.

Ongoing hospital management [8]

Supportive care

Optimizing chronic therapy for chronic HF [3][6][8]

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

Monitoring [3][6]

Treatment of refractory acute heart failure [8]

Consider the following if AHF persists despite maximal respiratory and hemodynamic support.

Hemodynamic supporttoggle arrow icon

Management depends on the classification of AHF. See “Management of cardiogenic shock” for details on therapeutic targets and monitoring.

Dry and cold AHF [8][37]

Wet and cold AHF [8][37]

Avoid inotropes in patients with left ventricular outflow tract obstruction (e.g., hypertrophic cardiomyopathy, aortic stenosis). [48]

Respiratory supporttoggle arrow icon

The cornerstones of respiratory support in acute heart failure are oxygen therapy and positive pressure ventilation, typically starting with the least invasive modality and escalating as needed. [8]

Initial measures [8]

Respiratory failure

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

Pharmacotherapytoggle arrow icon

Diuretic therapy in acute heart failure

Initial treatment

  • Administer diuretics intravenously, if possible.
  • Diuretic-naive patients: IV furosemide OR bumetanide [55]
  • Patients already taking diuretics: Administer 1–2.5 times the patient's usual oral dose intravenously as a bolus or continuous infusion. [36][55]

Continuing treatment

Use diuretics judiciously and assess volume status, electrolytes, and creatinine levels regularly to avoid overaggressive diuresis, as this may lead to hypotension, electrolyte imbalances, and/or a deterioration in renal function. [6][15]


Elevated creatinine is not a contraindication to diuretic therapy in patients with acute heart failure, as renal function typically improves with effective diuresis in cardiorenal syndrome. [59]

Vasodilator therapy in acute heart failure

For patients with hypertensive acute heart failure with pulmonary edema in the emergency department or prehospital setting, consider a single dose of sublingual nitroglycerine (i.e., nitroglycerine 0.4 mg sublingual once) while obtaining IV access and setting up an infusion. [36]

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

Complications and comorbiditiestoggle arrow icon


Atrial fibrillation with RVR [63]

See “Afib with heart failure.”

Cardiorenal syndrome

Cardiorenal syndrome causes prerenal acute kidney injury with hypervolemia. Management is complex and involves early nephrology input, fluid restriction, and diuretics (see “Hemodynamic support in patients with AKI”).

Dispositiontoggle arrow icon

Patients presenting with acute heart failure are usually initially managed in the emergency department; most require subsequent hospitalization.

Hospital admission criteria [3][9][36]

Consider admission for patients with any of the following:

Consider ICU admission for patients at high risk of deterioration, and/or patients with hemodynamic instability and/or respiratory failure requiring aggressive support. [9]

Discharge from the emergency department [3][9][36]

Discharge may be considered in selected patients with known chronic HF who have returned to their baseline status of health after initial management.

Acute management checklisttoggle arrow icon

All patients [12][36][37][65]

Hemodynamically stable patients [12][36][37][65]

Hemodynamically unstable patients [12][36][37][65]

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Referencestoggle arrow icon

  1. $Contributor Disclosures - Acute heart failure. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, was previously employed by OPEN Health Communications). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
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