Authors: Sean Cassidy, MS4; Blake Briggs, MD
Heart failure (HF) is a clinical syndrome caused by structural or functional impairment of ventricular filling or ejection. It’s categorized as: HF with reduced ejection fraction, HF with preserved ejection fraction, HF with improved ejection fraction. (6)
In the ED we mostly care about acute decompensation: sudden worsening congestion ± pump failure. Up to 50% of ADHF is HFpEF, meaning many patients don’t scream “classic CHF” on arrival. Perform a real history and physical to get to the bottom of these patients’ complaints. (3)
Etiology: the most common etiologies encountered in the ED are ischemic heart disease, hypertension, arrhythmias, serious infections, and in 40-50% of cases no trigger is found. (1,8)
Presentation
Common presenting features:
Dyspnea, Nocturia, Fatigue, Tachycardia, arrhythmias, S3 / S4, Pulsus alternans
Left vs Right sided HF (Boards still love this distinction; real life patients mix both)
- Left HF → pulmonary congestion: dyspnea on exertion → dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, rales, cool extremities.
- Right HF → systemic congestion: edema, JVD, hepatomegaly, ascites, abdominal discomfort. Most common cause of right HF is left HF.
Diagnosis
Physical exam: ADHF is primarily guided by the physical exam.
- In hypertensive patients with dyspnea/chest pain, think of pulmonary edema.
- In hypotensive and/or tachycardic patients, don’t just think “sepsis”! Volume assessment is critical in HF as this directs diuretic therapy. Listen for crackles/rales on lung auscultation, look for pitting edema, and use POCUS to inform your volume status decision (discussed below)
- S3 → highest LR+ for ADHF (7)
- Dyspnea on exertion → best sensitivity (7)
- Orthopnea + paroxysmal nocturnal dyspnea + peripheral edema → best specificity (7)
Labs – you will likely order the following: CBC (anemia), CMP (renal/hepatic function), troponin (ischemia).
When to order BNP/NT-proBNP (not just because your hospitalist wants it)
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- Use only when dyspnea is undifferentiated.
- BNP may aid in prognosis. Higher levels correlate with higher all-cause mortality at one year (2).
- Don’t use it as a standalone test. BNP increases with renal failure, age, sex, and BMI among others (2).
- Negative predictive value is great. If levels are low, ADHF is unlikely
Imaging/testing – Anyone with chest pain and dyspnea will get a CXR and EKG. CXR Findings of cardiomegaly, pulmonary edema, effusion, or interstitial edema support the diagnosis of HF, but absence of these findings does not rule out HF. (6,7) Ischemia is one of the most common causes of ADHF, so look for STEMI and STEMI-equivalents, ST and T wave abnormalities, or arrhythmias on EKG. Bedside POCUS is going to be most useful to answer these 4 diagnostic questions (7):
1. Pericardial effusion? 2. LV squeeze (qualitative assessment of LVEF)? 3. IVC collapse or plump and
Dilated? 4. Are B-lines present?
In real life, there are no single physical exam or lab findings that can slam dunk the diagnosis of HF.
Management
Patients presenting with dyspnea from ADHF require rapid assessment and stabilization. This includes airway assessment, continuous pulse oximetry and cardiac monitoring, upright positioning, supplementary oxygen and ventilatory support via NIV or intubation, and early diuretic use.
1. Volume assessment – Use bedside POCUS and physical exam findings to determine fluid status. This can help guide diuretic and respiratory support treatments.
2. Oxygenation and Ventilation – If mild symptoms (SpO2 <90%), start with nasal cannula and titrate up as needed. If moderate/severe distress, quickly ramp up to NIV (CPAP/BiPAP) early. NIV reduces intubation and mortality in pulmonary edema. If there is NIV failure, altered mental status, shock, or contraindications, get ready to intubate.
3. Vasodilators – Best for patients with hypertensive emergency, SCAPE (see separate study guide), severe dyspnea despite diuretics, and no hypotension. One or two sublingual nitroglycerin 0.4 mg tablets can be administered within 1-5 minutes until relief or until IV nitroglycerin drip can be set up (7). For those resistant to nitroglycerin, CCBs like nicardipine or clevidipine are second line agents to add.
4. Diuretic therapy – Patients in ADHF with volume overload should be promptly treated with IV diuretics. Furosemide 20-80 mg IV, Bumetanide 1mg IV, Torsemide 10-20 mg IV are the main drugs (2).
The Crashing ADHF Patient
These patients are critically ill and require rapid recognition and resuscitation. Clues: hypotension (SBP <90), cool extremities, AMS, oliguria, lactate bump. This is “don’t call it sepsis until proven otherwise.”
1. Vasopressors – Norepinephrine (NE) is first-line if MAP < 65 mmHg. Dopamine can be considered, but as a second line drug due to its association with dysrhythmias and increased mortality in cardiogenic shock (7). For cardiogenic shock, starting NE in hypotensive patients will temporize organ perfusion.
2. Inotropes – Epinephrine and dobutamine are first line here. Alternatively, dobutamine can be substituted with milrinone if treatment is ineffective (7). Inotropes might lower the patient’s blood pressure, so if the patient is hypotensive, remember to start norepinephrine first.
Now what? Immediate cardiology consult. If you have not done bedside POCUS, this would be a fantastic time to do that. Pertinent findings are mentioned above, as this can help guide therapy. Acute decompensated patients in cardiogenic shock may require LVAD/RVAD, impella, or even ECMO to maintain adequate circulation.
References
1. Amboss. Acute Decompensated Heart Failure. 2025. [cited 2025 Sep 18]. Available fromhttps://next.amboss.com/us/article/Aq0Rah?q=decompensated%20heart%20failure#Zb5e67aaec3dce907ac9de4ec78592fd9
2. Colucci WS. Natriuretic peptide measurement in heart failure. In: UpToDate, Li H (Ed), Wolters Kluwer. (Accessed Nov 13, 2025.)
3. Colucci WS. Treatment of acute decompensated heart failure: Specific therapies. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on Nov 1, 2025.)
4. Dunlay SM, Roger VL, Redfield MM. Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol 2017;14:591. [PubMed: 28492288]
5. Januzzi JL, van Kimmenade R, Lainchbury J, Bayes-Genis A, Ordonez-Llanos J, Santalo-Bel M, Pinto YM, Richards M. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006 Feb;27(3):330-7. doi: 10.1093/eurheartj/ehi631. Epub 2005 Nov 17. PMID: 16293638.
6. Shams P, Malik A, Chhabra L. Heart Failure (Congestive Heart Failure) [Updated 2025 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430873/
7. Storrow AB, Bales BD, Cox ZL, et al. Acute Heart Failure. In: Stapczynski J, Cline DM, Thomas SH, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide [Internet]. 9th ed. McGraw-Hill Education; 2025. Available from: https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=218080366.
8. Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol. 2016 Jun;13(6):368-78. doi: 10.1038/nrcardio.2016.25. Epub 2016 Mar 3. PMID: 26935038; PMCID: PMC4868779.
