Acute heart failure

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 8 Aug 2025

Last updated: 27 Feb 2025

Acute heart failure is a clinical syndrome of reduced cardiac output, tissue hypoperfusion, increased pulmonary pressure, and tissue congestion.

Presents with dyspnea, decreased exercise tolerance, swelling of the legs, fatigue, and generalized weakness.

Clinical diagnosis is supported by ancillary tests such as ECG, chest x-ray, B-type natriuretic peptide, and echocardiogram. In cases where echocardiographic images are suboptimal or when an unusual cause of heart failure is suspected, and for diagnosis of specific cardiomyopathies, other tests (e.g., cardiac catheterization with hemodynamic measurements, computed tomography, and cardiac magnetic resonance imaging) are used.

Diuretics, oxygen, and vasodilators are initial treatments for symptom relief. Cardiogenic shock may require vasoactive agents, mechanical ventilation, or mechanical circulatory support.

If acute myocardial infarction is present, early revascularization is essential.

Underlying cause or precipitant should be identified and treated.

Definition

Heart failure is defined clinically as a syndrome in which patients have symptoms and signs resulting from an abnormality of cardiac structure and/or function causing impairment of ventricular filling or ejection of blood.[1][2] Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.[1]

History and exam

Key diagnostic factors

older age
positive past medical history
dyspnea
pulmonary crepitations
peripheral edema
cool peripheries
chest pain
third heart sound (S3)

Full details

Other diagnostic factors

fatigue and weakness or decreased exercise tolerance
hypotension
tachycardia
elevated jugular venous pressure
displaced apex beat (point of maximal impulse)
dullness to percussion and decreased air entry in lung bases
wheezing
palpitations
cough
syncope
murmur
ascites
hepatomegaly
central cyanosis

Full details

Risk factors

older age
prior episode of heart failure
coronary artery disease
hypertension
valvular heart disease
pericardial disease
myocarditis
cardiac arrhythmias
atrial fibrillation
diabetes mellitus
nonadherence to medications
excessive salt intake
excessive catecholamine stimulation
abnormal thyroid function
excessive alcohol intake
obesity

Full details

Diagnostic tests

1st tests to order

ECG
chest x-ray
Hb
thyroid function test
B-type natriuretic peptide
troponin
echocardiography
electrolyte panel with BUN, serum creatinine, glucose
lipid profile
liver function tests

Full details

Tests to consider

lung ultrasound
cardiac catheterization
endomyocardial biopsy
cardiac magnetic resonance (CMR)
nuclear medicine imaging
cardiac CT (coronary CT angiogram)
additional biomarkers

Full details

Treatment algorithm

ACUTE

hemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis

ONGOING

acute episode stabilized: LVEF <50%

acute episode stabilized: LVEF ≥50%

Contributors

Expert advisers

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

Disclosures

SWY declares that he was a co-director of the American College of Cardiology (ACC) Cardiovascular Board Review Course during which he had also delivered lectures.

Acknowledgements

Dr Syed Wamique Yusuf would like to gratefully acknowledge Dr Daniel Lenihan, a previous contributor to this topic.

Disclosures

DL declares that he has no competing interests.

Peer reviewers

Amal Mattu, MD

Professor of Medicine

Department of Emergency Medicine

University of Maryland School of Medicine

Baltimore

Disclosures

AM declares that he has no competing interests.

David Whellan, MD

Assistant Professor of Medicine

Jefferson Medical College

Philadelphia

Disclosures

DW declares that he has no competing interests.

Katherine C. Wu, MD

Assistant Professor of Medicine

Johns Hopkins University School of Medicine

Baltimore

Disclosures

KCW declares that she has no competing interests.

Sanjay Sharma, BSc (Hons), FRCP (UK), MD

Consultant Cardiologist

King's College Hospital London

London

Disclosures

SS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726.Full text Abstract

Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 3;145(18):e895-1032.Full text Abstract

Ezekowitz JA, O'Meara E, McDonald MA, et al. 2017 comprehensive update of the Canadian Cardiovascular Society guidelines for the management of heart failure. Can J Cardiol. 2017 Nov;33(11):1342-433.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Pneumonia
- Pulmonary embolism
- Asthma
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Guidelines
- 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure
- 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure
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Videos
Central venous catheter insertion: animated demonstration
How to perform an ECG: animated demonstration
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Patient information
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Atrial fibrillation: what is it?
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Acute heart failure

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

hemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis

acute episode stabilized: LVEF <50%

acute episode stabilized: LVEF ≥50%

Contributors

Expert advisers

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Amal Mattu, MD

Disclosures

David Whellan, MD

Disclosures

Katherine C. Wu, MD

Disclosures

Sanjay Sharma, BSc (Hons), FRCP (UK), MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Videos

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice