Precipitants of Acute Heart Failure: A State-of-the-art Review from an International Expert Group

Acute heart failure (AHF) is a leading cause of hospitalisation worldwide, with the majority of cases triggered by an identifiable precipitant. Recognition of these precipitants is important for both acute management and long-term prevention, as they are frequently reversible, carry prognostic significance and directly inform targeted therapy. The epidemiology of precipitants varies across settings, and patterns are evolving as the prevalence of heart failure with preserved ejection fraction rises. In this review, we summarise the epidemiology, diagnostic evaluation and management of the most common precipitants of AHF. Globally, the leading precipitants of AHF are ischaemia/acute coronary syndrome, infection, arrhythmias, uncontrolled hypertension, nonadherence and renal dysfunction, although their relative distribution varies by geography and heart failure phenotype. Optimal medical management necessitates initial haemodynamic stabilisation, identification of the underlying precipitant and delivery of targeted therapy. Importantly, successful identification and treatment of a reversible precipitant should not preclude initiation or optimisation of guideline-directed medical therapy, which remain essential for long-term outcomes.