Acute decompensated heart failure (ADHF) has emerged as a major public health problem. In the US, heart failure is the primary diagnosis accounting for greater than one million hospital discharges annually. Prospective observational registries have improved our understanding of the clinical characteristics of patients who need to be hospitalized for ADHF. ADHF disproportionately affects the elderly. Half of patients hospitalized have normal or near normal left ventricular systolic function, 80% of patients have previously diagnosed heart failure, 70% have a history of hypertension, and half have an initial systolic blood pressure >140 mmHg. A small percentage of patients present in cardiogenic shock. Most patients present with shortness of breath and evidence of pulmonary congestion. Goals of therapy are to identify and treat acute causes of heart failure decompensation (especially acute coronary syndromes), stabilize respiratory status and blood pressure, relieve pulmonary and systemic venous congestion with intravenous diuretics, transition to oral medical therapy including a stable regimen of oral diuretics and an optimal regimen of guideline directed medical therapy (GDMT), and establish a discharge plan for transition of care and outpatient management.