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The aim of this study was to measure sublingual perfused capillary density (PCD) to assess sublingual microvascular perfusion during emergency department (ED) treatment of acute decompensated heart failure (ADHF).This prospective, observational study enrolled ED patients with ADHF, measuring pre- and post-ED treatment PCD. Sidestream dark-field imaging was analyzed by 3 investigators blinded to patient identifiers and time points. Patient demographics, ADHF etiology, serum brain natriuretic peptide, and hemoglobin were measured along with a visual analogue scale (VAS), which assessed patient baseline characteristics and response to ED treatment. A paired t test analyzed changes in PCD, mean arterial pressure (MAP), and patient assessment. Interrater variability was assessed with an intraclass correlation coefficient (ICC), with a P value <.05 considered significant for all testing.Thirty-six patients were enrolled with a mean time between pretreatment and posttreatment PCD (±SD) of 138 ± 59 minutes and a hospital length of stay of 4.0 ± 4.1 days. During this time, PCD increased (difference, 1.3 mm/mm2; 95% confidence interval, 0.4-2.1; P = .004), as did the MAP (P = .002), patient VAS score (P < .001), and observer VAS score (P < .001). There was no correlation between the change in PCD and time (R2 = .016, P = .47), MAP (R2 = .013, P = .54), or VAS scores. The ICC was 0.954.Sublingual tissue perfusion is diminished in ADHF but increases with treatment. It may represent a quantitative way to evaluate ADHF in the ED setting.