Congestive heart failure (CHF) is a clinical syndrome resulting from structural or functional cardiac impairment leading to inadequate cardiac output and/or elevated filling pressures, presenting most commonly with dyspnea, fluid overload, and exercise intolerance. [1-2] It is the most frequent cause of unplanned hospital admission in patients older than 65 years. [3]
1. History
- Key HPI questions: Onset and progression of dyspnea (exertional vs. rest), orthopnea (number of pillows), paroxysmal nocturnal dyspnea (PND), bendopnea, lower extremity swelling, weight gain, exercise tolerance, and fatigue [1][4]
- Symptom characterization: Dyspnea is the cardinal symptom; distinguish acute flash pulmonary edema from gradual decompensation. Quantify functional limitation using NYHA class (I–IV) [1]
- Timing/triggers: Ask about dietary indiscretion (salt/fluid), medication nonadherence, recent illness/infection, new medications (NSAIDs, verapamil), alcohol/substance use [2]
- Associated symptoms: Abdominal bloating, early satiety, right upper quadrant pain (hepatic congestion), nocturnal cough, wheezing ("cardiac asthma"), nocturia [1][4]
- Important negatives: Chest pain (ACS), palpitations (arrhythmia), fever (endocarditis/infection), hemoptysis (PE), syncope
2. Alarm Features
- Immediate risk: Hypoxia, shock/hypoperfusion, respiratory distress, anuria, acute coronary syndrome, hemodynamically significant arrhythmia, altered mental status [4]
- Cardiogenic shock signs: Cool/mottled extremities, narrow pulse pressure (≤0.25 of SBP), elevated lactate, oliguria, hypotension (may be a late finding) [2][5]
- Indicators for urgent escalation: Need for intubation/NIV, IV vasoactive agents, mechanical circulatory support, refractory pulmonary edema, new-onset HF with hemodynamic instability [6-7]
3. Medications
Medications that precipitate/worsen HF: [2]
- NSAIDs (sodium retention, increased afterload)
- Calcium channel blockers with negative inotropy (verapamil, diltiazem)
- Thiazolidinediones (fluid retention)
- Certain antiarrhythmics (flecainide, dronedarone in decompensated HF)
Core GDMT for HFrEF (the "four pillars"): [8-9]
- ARNI (sacubitril/valsartan) preferred over ACEi/ARB — start 49/51 mg BID, target 97/103 mg BID
- Evidence-based beta-blocker (carvedilol, metoprolol succinate, bisoprolol) — initiate when euvolemic and hemodynamically stable
- MRA (spironolactone 25–50 mg or eplerenone 25–50 mg daily)
- SGLT2 inhibitor (dapagliflozin 10 mg or empagliflozin 10 mg daily)
Acute decompensation: [2-3]
- IV loop diuretics (furosemide, bumetanide, torsemide) — cornerstone of decongestion
- Vasodilators (nitroglycerin, nitroprusside) for hypertensive acute HF
- Inotropes (dobutamine, milrinone) for cardiogenic shock/low-output states — use with caution
Additional agents: Hydralazine/isosorbide dinitrate (especially in self-identified Black patients), ivabradine (HR ≥70 in sinus rhythm on max beta-blocker), vericiguat (high-risk patients on max GDMT) [8-9]
The following table summarizes pharmacotherapy dosing for HFrEF:
4. Diet
- Sodium: Avoid excessive sodium intake (Class 2a recommendation); the 2022 AHA/ACC/HFSA guidelines do not specify a strict target but recommend avoidance of excess. The SODIUM-HF trial showed aggressive restriction (<1,500 mg/day) did not significantly improve outcomes [2][10]
- Dietary patterns: DASH and Mediterranean diets are associated with improved symptoms, functional capacity, and potentially reduced HF hospitalizations [11]
- Fluid restriction: Generally 1.5–2 L/day in patients with severe hyponatremia or refractory congestion
- Avoid: Excessive alcohol, processed foods high in sodium/saturated fat [12]
- Malnutrition/cachexia: Screen for malnutrition; overly restrictive diets may worsen micronutrient deficiency and caloric intake [11][13]
5. Review of Systems
- Cardiovascular: Chest pain, palpitations, syncope/presyncope, claudication
- Pulmonary: Cough (especially nocturnal/supine), wheezing, hemoptysis
- GI: Abdominal distension, early satiety, nausea, RUQ pain, anorexia
- Renal: Decreased urine output, nocturia, foamy urine
- Neurologic: Confusion, lightheadedness (low output)
- Endocrine: Cold/heat intolerance (thyroid), polyuria/polydipsia (diabetes)
- Psychiatric: Depression, cognitive impairment (common comorbidities)
6. Collateral History and Family History
- Collateral: Medication adherence, dietary compliance, baseline functional status, recent weight changes, substance use (alcohol, cocaine, methamphetamine)
- Family history: Dilated cardiomyopathy, hypertrophic cardiomyopathy, sudden cardiac death, arrhythmias, congenital heart disease, cardiac amyloidosis
- Social context: Access to medications, food insecurity, caregiver support, health literacy — social determinants significantly impact readmission risk [2][14]
7. Risk Factors
- Major: Coronary artery disease, hypertension, diabetes mellitus, valvular heart disease, obesity, prior MI [8]
- Lifestyle: Sedentary lifestyle, excessive alcohol use, smoking, high-sodium diet, illicit drug use (cocaine, methamphetamine)
- Comorbidities: CKD, atrial fibrillation, sleep apnea, COPD, thyroid disorders, anemia, iron deficiency [8]
- Cardiotoxic exposures: Anthracyclines, trastuzumab, radiation therapy [2]
- Other: Peripartum state, viral myocarditis (including COVID-19), familial/genetic cardiomyopathies [2]
8. Differential Diagnosis
- Pulmonary embolism: Acute dyspnea, pleuritic chest pain, tachycardia, hypoxia — CT angiography to differentiate
- COPD/asthma exacerbation: Wheezing, air trapping; may coexist with HF; BNP/NT-proBNP helps distinguish
- Pneumonia: Fever, productive cough, focal consolidation on CXR
- Acute coronary syndrome: Chest pain, ECG changes, troponin elevation — may precipitate HF
- Pericardial tamponade: Beck's triad, pulsus paradoxus, electrical alternans
- Nephrotic syndrome/cirrhosis: Edema and volume overload from non-cardiac causes
- Pulmonary hypertension: Right-sided failure, may mimic or coexist with HF
- High-output states: Thyrotoxicosis, severe anemia, AV fistula, Paget disease [1-2]
9. Past Medical History
- Prior HF hospitalizations (number, frequency, trajectory)
- Known EF and last echocardiogram date
- CAD, prior MI, PCI, or CABG
- Valvular disease or prior valve surgery
- Device history (ICD, CRT, LVAD)
- Arrhythmia history (especially atrial fibrillation)
- CKD stage, baseline creatinine
- Diabetes, hypertension, hyperlipidemia
- Cancer treatment history (cardiotoxic agents)
10. Physical Exam
- Vital signs: Tachycardia, hypotension or hypertension, tachypnea, hypoxia, narrow pulse pressure [1-2]
- JVP: Most sensitive sign of elevated filling pressures; assess with hepatojugular reflux [4]
- Cardiac: S3 gallop (volume overload), S4 (diastolic dysfunction), laterally displaced PMI, murmurs of MR/TR [1]
- Pulmonary: Rales/crackles (may be absent in chronic HF due to lymphatic compensation), pleural effusions, wheezing [1][4]
- Abdomen: Hepatomegaly (pulsatile in TR), ascites, RUQ tenderness
- Extremities: Peripheral/pedal edema, presacral edema (in supine patients), cool/mottled extremities (low output) [1]
- General: Cachexia/muscle wasting (advanced HF), Cheyne-Stokes respirations
11. Lab Studies
Per the 2022 AHA/ACC/HFSA guidelines, the following are recommended (Class 1): [2]
- BNP or NT-proBNP: Diagnosis, severity, prognosis. NT-proBNP ≤125 pg/mL effectively excludes HF. Reduced sensitivity with obesity and HFpEF [2][15]
- BMP: Electrolytes (Na, K, Mg, Ca), BUN, creatinine, glucose — monitor renal function and electrolytes with diuretics
- CBC: Anemia workup
- Liver function tests: Hepatic congestion
- Iron studies: Ferritin, transferrin saturation — iron deficiency is common and treatable
- TSH: Thyroid dysfunction as reversible cause
- Troponin: Rule out ACS as precipitant; elevated troponin without ACS confers intermediate risk [4]
- Lactate: If concern for cardiogenic shock/hypoperfusion [2]
- Lipid panel, HbA1c, urinalysis: Baseline evaluation [2]
12. Imaging
- Chest X-ray (first-line): Cardiomegaly (64–79% sensitivity), cephalization of vessels, Kerley B lines, pleural effusions, alveolar edema (≥95% specificity). ~20% of acute HF patients have no CXR congestion [1]
- Transthoracic echocardiography (essential): Confirms diagnosis — LVEF, chamber dimensions, wall motion, valvular disease, diastolic function, estimated PA pressures, volume status [1][15]
- Cardiac MRI: Tissue characterization (myocarditis, sarcoidosis, amyloidosis, hemochromatosis), ischemic vs. nonischemic scar [16]
- Coronary angiography or CCTA: Evaluate for ischemic etiology in new-onset HFrEF [1]
- Lung ultrasound: Increasingly used at point of care for B-lines (pulmonary congestion) and pleural effusions [14]
13. Special Tests
- Ottawa Heart Failure Risk Score (OHFRS): Validated ED risk stratification tool for disposition decisions [7]
- MEESSI and EHMRG scores: Additional risk stratification tools for acute HF in the ED [7]
- Point-of-care ultrasound (POCUS): IVC collapsibility for volume assessment, lung B-lines, cardiac function
- Right heart catheterization: When clinical assessment is uncertain; measures filling pressures, cardiac output, PVR — guides advanced therapy decisions [1]
- Endomyocardial biopsy: Suspected giant cell myocarditis, sarcoidosis, or infiltrative disease when diagnosis would change management [16]
- 6-minute walk test: Functional capacity assessment
- Cardiopulmonary exercise testing: Peak VO2 for advanced HF/transplant evaluation
14. ECG
- Indications: All patients presenting with HF (Class 1 recommendation) [2]
- Key findings: Atrial fibrillation/flutter, LVH, pathologic Q waves (prior MI), LBBB (CRT candidacy if QRS ≥150 ms), ST-T changes (ischemia), low voltage (amyloidosis, pericardial effusion), prolonged QTc
- Dangerous patterns: ST elevation (STEMI), ventricular tachycardia, high-degree AV block, new LBBB with hemodynamic instability
15. Assessment
- Classify by EF: HFrEF (≤40%), HFmrEF (41–49%), HFpEF (≥50%) — treatment differs significantly [2]
- Stage (ACC/AHA): A (at risk), B (pre-HF), C (symptomatic), D (advanced/refractory) [2]
- NYHA functional class: I–IV for symptom severity [1]
- Hemodynamic profile: Warm-dry, warm-wet, cold-dry, cold-wet — guides acute management [4]
- Identify precipitant: Nonadherence, ACS, arrhythmia, infection, uncontrolled HTN, thyroid disease, anemia, medication-related [2]
- Complications: Cardiogenic shock, arrhythmias, cardiorenal syndrome, thromboembolic events, cardiac cachexia
16. Treatment Plan
Acute decompensation: [2-3][5]
- Oxygen/ventilation: Supplemental O2 for hypoxia; BiPAP/CPAP for respiratory distress (reduces intubation rates, decreases preload and LV afterload)
- IV diuretics: Furosemide 20–40 mg IV (diuretic-naïve) or 1–2.5× home oral dose IV (chronic users); reassess response at 2–6 hours [2]
- Diuretic resistance: Add metolazone 2.5–5 mg PO 30 min before loop diuretic, or IV chlorothiazide; consider acetazolamide [9]
- Vasodilators: IV nitroglycerin for hypertensive acute HF (SBP >140)
- Inotropes/vasopressors: Dobutamine or milrinone for cardiogenic shock; norepinephrine for refractory hypotension
Chronic management (HFrEF) — initiate all four pillars simultaneously or in rapid sequence: [8][15]
- ARNI (or ACEi/ARB) — 36-hour washout when switching from ACEi to ARNI
- Evidence-based beta-blocker — initiate when euvolemic
- MRA
- SGLT2 inhibitor
Titrate to target doses over 3–6 months. [1] The following algorithm illustrates the treatment approach:
Additional therapies: IV iron for iron deficiency (Class IIa), cardiac rehabilitation (Class 1), ICD for primary prevention (LVEF ≤35% after ≥3 months of GDMT), CRT for LBBB with QRS ≥150 ms [8]
17. Disposition
Admit: [4][7]
- Critically ill: Hypoxia, shock, respiratory failure, hemodynamically significant arrhythmia
- New-onset HF requiring workup
- Significant congestion not rapidly responsive to ED treatment
- Intermediate-risk features: Tachycardia, renal dysfunction, hyponatremia, elevated troponin, markedly elevated BNP
ICU admission: Requiring continuous vasoactive infusions, mechanical ventilation, or mechanical circulatory support [7]
Observation/short stay: Known HF with mild exacerbation, clear correctable trigger (e.g., brief lapse in diuretics), brisk diuretic response, low OHFRS score [4][7]
Discharge criteria: [4]
- Resolution of congestion symptoms and signs
- Stable on oral diuretics for ≥24 hours before discharge (associated with reduced 30- and 90-day readmissions)
- Stable vital signs, adequate renal function
- GDMT initiated or optimized
- Discharge education completed
18. Follow Up / Return Precautions
- Follow-up: Within 7 days of discharge (ideally in an HF clinic); phone call within 48–72 hours [2][14]
- Daily weight monitoring: Return if weight gain >2–3 lbs in 24 hours or >5 lbs in a week
- Return precautions: Worsening dyspnea, new/worsening edema, chest pain, syncope/presyncope, inability to lie flat, decreased urine output, confusion
- Ongoing management: GDMT uptitration at each visit, cardiac rehabilitation referral, reassess EF at 3–6 months, advance directives/palliative care discussion for advanced disease [18-19]
- Expected course: Symptoms should improve within days of adequate decongestion; GDMT optimization over weeks to months can improve EF and functional status [1]
References
1. Heart Failure With Reduced Ejection Fraction: A Review. — Murphy SP, Ibrahim NE, Januzzi JL. The Journal of the American Medical Association. 2020.
2. 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. — Heidenreich PA, Bozkurt B, Aguilar D, et al. Journal of the American College of Cardiology. 2022.
3. Acute Heart Failure: Current Pharmacological Treatment and Perspectives. — Deniau B, Costanzo MR, Sliwa K, et al. European Heart Journal. 2023.
4. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. — Hollenberg SM, Warner Stevenson L, Ahmad T, et al. Journal of the American College of Cardiology. 2019.
5. Evaluation and Management of the Child With Acute Decompensated Heart Failure: A Scientific Statement From the American Heart Association. — Cabrera AG, Price JF, Hong BJ, et al. Circulation. 2026.
6. Standardized Definitions for Evaluation Of Acute Decompensated Heart Failure Therapies: HF-ARC Expert Panel Paper. — Lala A, Hamo CE, Bozkurt B, et al. JACC. Heart Failure. 2024.
7. Disposition of Acute Decompensated Heart Failure From the Emergency Department: An Evidence-Based Review. — Rider I, Sorensen M, Brady WJ, et al. The American Journal of Emergency Medicine. 2021.
8. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. — Maddox TM, Januzzi JL, Allen LA, et al. Journal of the American College of Cardiology. 2024.
9. Heart Failure With Reduced Ejection Fraction: Medical Management. — Gauer RL, Rifaat A, Foulkrod AM. American Family Physician. 2025.
10. The Continuum of Prevention and Heart Failure in Cardiovascular Medicine: A Joint Scientific Statement From the Heart Failure Society of America and the American Society for Preventive Cardiology. — Lala A, Beavers C, Blumer V, et al. Journal of Cardiac Failure. 2025.
11. Nutrition Assessment and Dietary Interventions in Heart Failure: JACC Review Topic Of the Week. — Driggin E, Cohen LP, Gallagher D, et al. Journal of the American College of Cardiology. 2022.
12. Cardiovascular, Kidney, and Metabolic Health: An Actionable Vision for Heart Failure Prevention. — Ostrominski JW, Cheng AYY, Nelson AJ, et al. Lancet. 2025.
13. Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions: A Scientific Statement From the American Heart Association. — Vest AR, DiDomenico RJ, Lichtenstein L, et al. Circulation. 2026.
14. Optimizing Pre-to-Post Discharge Transition of Care in Patients Hospitalized for Heart Failure - Part 3 of the International Expert Opinion Series on Acute Heart Failure Management. — Salah HM, Ambrosy AP, Biegus J, et al. Journal of Cardiac Failure. 2025.
15. Heart Failure With Reduced Ejection Fraction. — Cannata A, Crespo-Leiro MG, Bromage DI, Ruschitzka F, McDonagh TA. Lancet. 2025.
16. ACC/AHA Versus ESC Guidelines On Heart Failure: JACC Guideline Comparison. — van der Meer P, Gaggin HK, Dec GW. Journal of the American College of Cardiology. 2019.
17. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. — Writing Committee, Maddox TM, Januzzi JL, et al. Journal of the American College of Cardiology. 2021.
18. 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update: A Report of the American College of Cardiology Solution Set Oversight Committee. — Hollenberg SM, Stevenson LW, Ahmad T, et al. Journal of the American College of Cardiology. 2024.
19. From Hospital to Home: Evidence-Based Care for Worsening Heart Failure. — Oskouie S, Pandey A, Sauer AJ, et al. JACC. Advances. 2024.