Acute heart failure

Last reviewed: 27 Oct 2022
Last updated: 25 Aug 2022
25 Aug 2022

New US guidance includes updated recommendations on classification of heart failure, prevention, and treatment of symptomatic disease

A joint guideline has been released by the American Heart Association, American College of Cardiology, and Heart Failure Society of America. Revised recommendations, based on contemporary evidence and acknowledging the increasingly diverse heart failure patient populations seen in practice, include:

  • A heart failure classification that includes heart failure with mildly reduced ejection fraction (HFmrEF; ejection fraction 41%-49%) and heart failure with improved ejection fraction (HFimpEF; previous ejection fraction ≤40% improved to >40% after follow-up measurement), alongside existing categories (heart failure with reduced ejection fraction [ejection fraction ≤40%] and heart failure with preserved ejection fraction [ejection fraction ≥50%])

  • Indications for temporary and durable mechanical circulatory support (MCS) in patients with advanced heart failure

  • Post-stabilization therapy for patients with heart failure with reduced ejection fraction (ejection fraction ≤40%) now includes drugs from four medication classes, including sodium-glucose cotransporter 2 (SGLT2) inhibitors (e.g., dapagliflozin or empagliflozin) regardless of whether they have type 2 diabetes mellitus.

See Management: approach

See Etiology

See Management: treatment algorithm

Original source of update



History and exam

Key diagnostic factors

  • age >70 years
  • positive past medical history
  • dyspnea
  • pulmonary crepitations
  • peripheral edema
  • 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 heart failure
  • coronary artery disease
  • hypertension
  • valvular heart disease
  • pericardial disease
  • myocarditis
  • atrial fibrillation
  • diabetes mellitus
  • nonadherence 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
  • thyroid function test
  • B-type natriuretic peptide
  • troponin
  • echocardiography
  • electrolyte panel with BUN, serum creatinine, glucose
  • lipid profile
  • liver function tests
More 1st investigations to order

Investigations to consider

  • cardiac catheterization
  • 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


hemodynamically stable

hypotensive (systolic BP <90 mmHg)

hypertensive crisis


acute episode stabilized: LVEF <50%

acute episode stabilized: 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 was a co-director of the American College of Cardiology (ACC) Cardiovascular Board Review Course during which he had also delivered 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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