Acute heart failure

When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Last reviewed: 19 Apr 2025
Last updated: 27 Feb 2025

Summary

Definition

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

TX

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

MD

Disclosures

AM declares that he has no competing interests.

David Whellan, MD

Assistant Professor of Medicine

Jefferson Medical College

Philadelphia

PA

Disclosures

DW declares that he has no competing interests.

Katherine C. Wu, MD

Assistant Professor of Medicine

Johns Hopkins University School of Medicine

Baltimore

MD

Disclosures

KCW declares that she has no competing interests.

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

Consultant Cardiologist

King's College Hospital London

London

UK

Disclosures

SS declares that he has no competing interests.

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.
  • Acute heart failure images
  • Differentials

    • Pneumonia
    • Pulmonary embolism
    • Asthma
    More Differentials
  • 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
    More Guidelines
  • Videos

    Central venous catheter insertion: animated demonstration

    How to perform an ECG: animated demonstration

    More videos
  • Patient information

    Atrial fibrillation

    Atrial fibrillation: what is it?

    More Patient information
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer