Acute Heart Failure

Overview of Acute Heart Failure

Heart failure is a chronic, progressive condition in which the heart muscle cannot pump enough blood to meet the body’s demands. Acute heart failure is the rapid onset of new or worsening signs and symptoms of heart failure. It can occur on the left, right, or both sides of the heart, with right-sided failure usually caused by left-sided failure. Acute decompensated heart failure shows the same signs or symptoms as heart failure and occurs in patients with heart conditions like coronary artery disease.1-3

There are two types of left-sided heart failure:4

  • Acute systolic heart failure. Also known as heart failure with reduced ejection fraction (HFrEF). Occurs when the left ventricle loses its ability to contract normally. The heart then cannot pump with enough force to transport blood throughout the body.
  • Acute diastolic heart failure. Also known as heart failure with preserved ejection fraction (HFpEF). Occurs when the left ventricle loses its ability to relax normally due to heart muscle stiffness. The heart then cannot fill correctly with blood during the resting period between each beat.

Right-sided heart failure occurs when the right ventricle becomes damaged and loses pumping power, typically due to issues stemming from left-sided failure. Right-sided failure causes blood to get backed up in the veins, leading to congestion throughout the body.5

Acute congestive heart failure is a term that is often used interchangeably with acute heart failure, but it refers explicitly to acute heart failure that results in an accumulation of blood in other parts of the body, most commonly in the lungs and lower extremities. Additionally, acute decompensated heart failure presents the same signs and symptoms as acute heart failure. No matter the type, acute heart failure is a potentially life-threatening medical emergency that requires immediate medical attention.

De novo acute heart failure refers to patients presenting for the first time with the typical symptoms and signs of heart failure. Acute decompensated heart failure applies to patients experiencing acute heart failure who have pre-existing cardiomyopathy. While de novo acute heart failure occurs in patients without a history of heart disease, it should be noted that these patients typically have other ongoing health conditions that damage the heart.5

Causes of Acute Heart Failure & Presentation

Acute heart failure can present with a variety of symptoms, with one of the most common being shortness of breath (dyspnea). Other symptoms can include:5

  • Fatigue and weakness
  • Rapid or irregular heartbeat
  • Swelling in the legs, ankles, feet, abdomen, and veins of the neck
  • Persistent cough or wheezing
  • Chest pain
  • Difficulty concentrating or decreased alertness
  • Rapid weight gain from fluid buildup
  • Reduced ability to exercise
  • Nausea and lack of appetite

There is a wide variety of etiologies of acute heart failure. Anything that damages the heart or makes it work too hard can lead to acute heart failure. This includes lifestyle factors as well as pre-existing medical conditions. Some conditions that can potentially lead to heart failure are:3

  • Abnormal heart rhythm (arrhythmia or dysrhythmia)
  • Abnormal heart valves
  • Advanced kidney disease
  • Alcoholism
  • Blood clot in the lung (pulmonary embolism)
  • Heart defects present at birth (congenital heart disease)
  • Coronary artery disease
  • Diabetes
  • Heart muscle disease (dilated cardiomyopathy or hypertrophic cardiomyopathy)
  • Heart muscle inflammation (myocarditis)
  • High blood pressure (hypertension)
  • Low red blood cell count (severe anemia)
  • Obesity
  • Overactive thyroid (hyperthyroidism)
  • Past heart attack (myocardial infarction)
  • Severe lung disease
  • Stroke

Acute Heart Failure Diagnostic Workup

The diagnostic workup for acute heart failure begins with a rapid assessment of the patient’s health history, including a detailed account of any symptoms, history of heart disease in the family, whether the patient smokes, what medications they take, and if they have any other medical conditions.

The physical examination should be comprehensive. Patients with acute decompensated heart failure will present a general appearance that includes anxiety, diaphoresis, and poor nutritional status.6

Physicians often use the Framingham Diagnostic Criteria for Heart Failure, which requires the presence of either two major criteria or one major and two minor criteria to make the diagnosis.5 The criteria are as follows:5

Major Acute Heart Failure Criteria

  • Acute pulmonary edema
  • Cardiomegaly
  • Hepatojugular reflex
  • Neck vein distention
  • Paroxysmal nocturnal dyspnea or orthopnea
  • Pulmonary rales
  • Third heart sound (S3 Gallop)
  • Weight loss of 4.5 kg or more in 5 days in response to treatment
  • Central venous pressure greater than 16 cm of water
  • Radiographic cardiomegaly

Minor Acute Heart Failure Criteria

  • Ankle edema
  • Dyspnea on exertion
  • Hepatomegaly
  • Nocturnal cough
  • Pleural effusion
  • Tachycardia (heart rate greater than 120 beats per minute)
  • A decrease in vital capacity by one-third of the maximal value recorded

Diagnostic testing that can also be used to help diagnose acute heart failure, as well as potential underlying etiologies, includes blood tests, chest x-ray, electrocardiogram, echocardiogram, stress tests, cardiac computerized tomography (CT) scan, magnetic resonance imaging (MRI), coronary angiogram, and myocardial biopsy.7

Acute Heart Failure Differential Diagnosis

There is a broad differential diagnosis of heart failure, including the following:

  • Acute kidney injury
  • Acute respiratory distress syndrome
  • Bacterial pneumonia
  • Cardiogenic pulmonary edema
  • Chronic obstructive pulmonary disease
  • Cirrhosis
  • Community-acquired pneumonia
  • Goodpasture syndrome
  • Idiopathic pulmonary fibrosis
  • Interstitial (non-idiopathic) pulmonary fibrosis
  • Myocardial infarction
  • Nephrotic syndrome
  • Neurogenic pulmonary edema
  • Pulmonary embolism
  • Pneumothorax
  • Respiratory failure
  • Viral pneumonia
  • Venous insufficiency

Acute Heart Failure Management (Nonpharmacotherapy and Pharmacotherapy)

Acute heart failure management largely depends on the severity of the symptoms. Two main classification systems are used to determine the severity based on symptoms. Often, both systems are used to decide which treatment options are best for the patient.

American College of Cardiology/American Heart Association Classification

  • Stage A: At high risk for heart failure but no structural heart disease or symptoms of heart failure
  • Stage B: Asymptomatic left ventricular dysfunction: structural heart disease but no symptoms or signs of heart failure
  • Stage C: Overt heart failure: structural heart disease with symptoms of heart failure
  • Stage D: Refractory heart failure

*Symptoms of heart failure are only in stages C and D.

New York Heart Association Classification1

  • Class I: Asymptomatic left ventricular dysfunction with no limitations on physical activity or symptoms.
  • Class II: Mild symptoms with slight limitation of physical activity. Ordinary activities lead to symptoms.
  • Class III: Moderate symptoms with marked limitation of physical activity. Less than ordinary activities lead to symptoms.
  • Class IV: Severe symptoms while at rest.

Nonpharmacological treatment is always indicated, with the ultimate goal of preventing overt heart failure by controlling the risk factors. This mainly comprises behavioral and lifestyle modifications, including dietary and nutritional consultation; strict adherence to therapy and diet; daily weight and diuretic dosing adjustment for sudden weight changes; aerobic exercise training; controlling of high blood pressure, heart rhythm abnormalities, or anemia; and discontinuing the use of tobacco, alcohol, and illicit drugs.

Other more serious nonpharmacological treatments include the use of implantable cardioverter-defibrillators for ICD shock, cardiac resynchronization therapy (CRT), coronary revascularization, heart transplantation, ventricular assist devices (VADs), and surgical ventricular restoration (SVR).6 These treatment options should be carefully considered based on the individual case. In most instances, pharmacological intervention should be attempted first, if possible.

Pharmacological interventions include:8

  • Angiotensin system blocker (ACE inhibitors, ARB, or ARNI)
  • Aspirin and statin
  • Beta blockers
  • Continuous intravenous inotrope
  • Digoxin
  • Diuretics
  • Ivabradine
  • Mineralocorticoid Receptor Antagonists (MRAs)
  • Nitrates Plus Hydralazine
  • Sodium-glucose cotransporter 2 inhibitor

Acute Heart Failure Complications

Complications of acute heart failure depend on the patient’s overall health, the severity of heart disease, and other factors such as age and treatment determinations. Possible complications can include:8

  • Arrhythmia/Dysrhythmia
  • Decreased functional capacity
  • Decreased quality of life
  • Liver dysfunction (hepatic congestion)
  • Myocardial infarction
  • Pulmonary hypertension
  • Renal dysfunction or failure (cardiorenal disease)
  • Sudden cardiac death
  • Unintentional weight loss (cardiac cachexia)
  • Valvular dysfunction with dilated cardiomyopathy

Monitoring Acute Heart Failure Post Care

One of the most common causes of heart failure readmission is the failure to comply with diet or medications. Careful monitoring combined with patient education is critical in preventing the associated morbidity and mortality of this disease.

The ACC/AHA recommends patient education to facilitate self-care and compliance, as well as close supervision in home-based visits, telephone support, and remote monitoring to prevent adverse outcomes. Patients need frequent in-depth education and re-evaluation to ensure adherence to recommendations.


1. Kurmani S, Squire I. Acute Heart Failure: Definition, Classification and Epidemiology. Current Heart Failure Reports. 2017;14(5):385-392. doi:10.1007/s11897-017-0351-y

2. Acute Heart Failure: Types, Symptoms, Causes and Treatment. Cleveland Clinic. Accessed June 29, 2022.

3. Heart Failure. Centers for Disease Control and Prevention. Published September 8, 2020. Accessed June 29, 2022.

4. Heart Failure – What Is Heart Failure? National Heart, Lung, and Blood Institute. Published March 24, 2022. Accessed June 29, 2022.

5. 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;145(18). doi:10.1161/cir.0000000000001063

6. Understanding Heart Failure. Cleveland Clinic. Published 2015. Accessed June 29, 2022.

7. Malik A, Brito D, Vaqar S, Chhabra L. Heart Failure, Congestive (CHF). National Library of Medicine. Published 2018. Accessed June 29, 2022.

8. Hajouli S, Ludhwani D. Heart Failure And Ejection Fraction. NIH | National Library of Medicine. Published January 18, 2020. Accessed June 29, 2022.

Author Bio

Jonathan Poole is a freelance writer and copyeditor with a BSc in Exercise Science living in West Lafayette, IN. When not writing, he owns and operates a fitness training company, Unstoppable Athletes.