Acute heart failure (AHF) is life-threatening emergency. AHF is a term used to describe the sudden onset or worsening of the symptoms of heart failure. Thus it may present with or without a background history of pre-existing heart failure. AHF without a past history of heart failure is called de-novo AHF. Decompensated AHF is more common (66-75%) and presents with a background history of HF.


  • Incidence: 200.00 cases per 100,000 person-years
  • Peak incidence: 70+ years
  • Sex ratio: 1:1
Condition Relative
Acute exacerbation of COPD3.75
Acute heart failure1
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+


AHF is usually caused by a reduced cardiac output that results from a functional or structural abnormality.

De-novo heart failure is caused by and increased cardiac filling pressures and myocardial dysfunction usually as a result of ischaemia. This causes reduced cardiac output and therefore hypoperfusion. This, in turn can cause pulmonary oedema. Other less common causes of de-novo AHF are:
  • Viral myopathy
  • Toxins
  • Valve dysfunction

Decompensated heart failure accounts for most cases of AHF. The most common precipitating causes of acute AHF are:

There is generally a history of pre-existing cardiomyopathy. It usually presents with signs of fluid congestion, weight gain, orthopnoea and breathlessness.

Clinical features

Generally speaking, the signs and symptoms of AHF are as follows:

Reduced exercise toleranceTachycardia
OedemaElevated jugular venous pressure
FaitgueDisplaced apex beat
Chest signs: classically bibasal crackles but may also cause a wheeze
S3-heart sound

Sometimes the presentation will be that of the underlying cause (e.g: chest pain, viral infection)

Over 90% of patients with AHF have a normal or increased blood pressure (mmHg).


The diagnostic workup for patients with AHF includes:
  • Blood tests – this is to look for any underlying abnormality such as anaemia, abnormal electrolytes or infection.
  • Chest X-ray – findings include pulmonary venous congestion, interstitial oedema and cardiomegaly
  • Echocardiogram – this will identify pericardial effusion and cardiac tamponade
  • B-type natriuretic peptide – raised levels (>100mg/litre) indicate myocardial damage and are supportive of the diagnosis.


Management options in acute heart failure include:
  • oxygen
  • diuretics
  • opiates
  • vasodilators
  • inotropic agents
  • CPAP
  • ultrafiltration
  • mechanical circulatory assistance: e.g. intra-aortic balloon counterpulsation or ventricular assist devices

Consideration should be given to discontinuing beta-blockers in the short-term.