Acute exacerbation of congestive heart failure

Last reviewed: 12 Jul 2022
Last updated: 20 Apr 2022



History and exam

Key diagnostic factors

  • presence of risk factors (previous cardiovascular disease, age >70 years)
  • dyspnoea
  • pulmonary crepitations
  • peripheral oedema
  • cool peripheries
  • chest pain
  • third heart sound (S3)
More key diagnostic factors

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
  • fever
  • syncope
  • murmur
  • ascites
  • hepatomegaly
  • central cyanosis
Other diagnostic factors

Risk factors

  • age >70 years
  • prior episode of congestive heart failure (CHF)
  • coronary artery disease
  • hypertension
  • valvular heart disease
  • pericardial disease
  • myocarditis
  • atrial fibrillation
  • diabetes mellitus
  • non-adherence to medications
  • excessive salt intake
  • excessive catecholamine stimulation
  • abnormal thyroid function
  • excessive alcohol intake
More risk factors

Diagnostic investigations

1st investigations to order

  • ECG
  • chest x-ray
  • Hb
  • TFT
  • troponin
  • B-type natriuretic peptide
  • echocardiography
More 1st investigations to order

Investigations to consider

  • cardiac catheterisation
  • endomyocardial biopsy
  • cardiac magnetic resonance (CMR)
  • single-photon emission CT
  • positron emission tomography with or without CT
  • cardiac CT (coronary CT angiogram)
  • additional biomarkers
More investigations to consider

Treatment algorithm


haemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis


acute episode stabilised: LVEF <50% and systolic BP >100 mmHg

acute episode stabilised: LVEF <50% and systolic BP 90-100 mmHg

acute episode stabilised: LVEF ≥50%



Syed Wamique Yusuf, MBBS, FACC, FRCPI
Syed Wamique Yusuf

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center




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


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


DL declares that he has no competing interests.

Peer reviewers

David Whellan, MD

Assistant Professor of Medicine

Jefferson Medical College




DW declares that he has no competing interests.

Katherine C. Wu, MD

Assistant Professor of Medicine

Johns Hopkins University School of Medicine




KCW declares that she has no competing interests.

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

Consultant Cardiologist

King's College Hospital London




SS declares that he has no competing interests.

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