💜 Contemporary Management of Acute Heart Failure: From Emergency Presentation to Long-Term Remission Acute heart failure (AHF) remains one of the leading causes of hospitalization worldwide, with persistently high mortality and readmission rates. This comprehensive 2026 JACC State-of-the-Art Review proposes a practical shift in our approach: hospitalization should no longer be viewed merely as a decongestion episode, but as a critical disease-modifying opportunity to optimize long-term outcomes. Several key messages emerge. First, congestion remains the primary therapeutic target. The authors emphasize rapid administration of intravenous loop diuretics based on clinical suspicion rather than waiting for confirmatory testing. Importantly, diuretic response should be evaluated within 2 hours using urine output (>300 mL) and, when available, spot urinary sodium (>70 mmol/L). Failure to achieve these targets should trigger immediate escalation of decongestive therapy. Second, the review introduces the SPLASH framework for early bedside assessment: • Symptoms • Past medical history • Life signs • Assessment of congestion • STEMI or equivalent exclusion • Hypoperfusion This structured approach aims to improve diagnostic accuracy and accelerate treatment initiation. Third, the review strongly supports early implementation of guideline-directed medical therapy (GDMT). Hospitalization is described as the ideal moment to initiate or rapidly uptitrate the four pillars of heart failure treatment: • ARNI/RAS inhibition • Beta blockers • Mineralocorticoid receptor antagonists • SGLT2 inhibitors The authors highlight evidence from STRONG-HF, EMPULSE, PIONEER-HF, and SOLOIST-WHF demonstrating that early initiation reduces mortality, rehospitalization, and improves quality of life. Perhaps the most important practical message is that therapy optimization should begin before discharge rather than being deferred to outpatient follow-up. The review advocates frequent early post-discharge visits and rapid titration strategies to achieve full GDMT implementation within weeks rather than months. Another notable concept is the emphasis on complete decongestion. Residual congestion at discharge remains common and is consistently associated with worse outcomes. Multimodal assessment combining clinical examination, natriuretic peptides, echocardiography, and lung ultrasound is recommended to avoid premature discharge. The future of AHF management is not simply treating congestion. It is using hospitalization as a strategic opportunity to alter the disease trajectory. Reference 📚 Bruno J, Arrigo M, Baudry G, et al. Contemporary Management of Acute Heart Failure: From Emergency Presentation to Long-Term Remission. Journal of the American College of Cardiology. 2026. doi:10.1016/j.jacc.2026.03.029