Heart failure is a common presentation to the emergency department (ED), which can be confusedwith other clinical conditions. This review provides an evidence-based summary of the currentED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heartfailure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea,orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heartsound, or extremity edema. However, physical examination findings are often not sensitive or specific.ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liverfunction tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriureticpeptides do not significantly change ED treatment, mortality, or readmission rates, although they maydecrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and severalother conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound,which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cavasize. These modalities, combined with clinical assessment and gestalt, are recommended.