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Acute decompensated heart failure (ADHF) is a common syndrome with diverse etiologies and precipitating factors, which is associated with significant morbidity and mortality. Tremendous resources are used in treating this syndrome, with few prospectively designed clinical trials to guide therapy. Patients suffering from ADHF are at increased risk for readmission to the hospital as well as an increased risk of death. Prompt identification and management of these patients can lead to shorter length of hospital stay, lower likelihood of readmission, and, perhaps, lower mortality. Initial treatment should target the relief of congestive symptoms. Intravenous loop diuretics are the mainstay of therapy, whereas ultrafiltration has emerged as a viable option in patients refractory to conventional treatment with diuretics. The safety and efficacy of nesiritide have been clarified in a recent large randomized trial, reassuring a favorable safety profile, but with modest improvement in short-term clinical outcomes. Thus, the preferred intravenous vasoactive medication has yet to be determined in large clinical trials, and positive inotropic agents should be reserved for patients with hemodynamic collapse. This article reviews the in-hospital assessment and management of ADHF.