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.

Acute heart failure

Last reviewed: 30 Oct 2023
Last updated: 25 Aug 2022



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.

  • Acute heart failure images
  • Differentials

    • Pneumonia
    • Pulmonary embolism
    • Asthma
    More Differentials
  • Guidelines

    • 2022 AHA/ACC/HFSA guideline for the management of heart failure
    • Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute heart failure syndromes
    More Guidelines
  • Patient leaflets

    Atrial fibrillation

    Atrial fibrillation: what is it?

    More Patient leaflets
  • Videos

    Central venous catheter insertion: animated demonstration

    How to perform an ECG: animated demonstration

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

Use of this content is subject to our disclaimer