Acute decompensated heart failure (ADHF) is the primary diagnosis for approximately one million hospital admissions in the United States, with an estimated $13.6 billion dollars of direct hospital cost in 2003. Until recently, diagnosis and management of ADHF has largely been “tradition-based” rather than evidence-based. Diuretic therapy has been the mainstay of symptom relief for pulmonary congestion and fluid retention. The introduction of nesiritide has revived the emphasis on vasodilator therapy for preload and afterload reduction in ADHF. Newer intravenous vasodilator drugs such as tezosentan, an endothelin antagonist, and carperitide, a natriuretic peptide, currently are being tested in multicenter clinical trials. New inotropic agents, such as levosimendan, appear to have an improved safety and efficacy profile. Vasopressin receptor antagonists and adenosine receptor antagonists may offer improved renal preservation during aggressive diuresis. Mechanical unloading with ultrafiltration devices and extracorporeal circulatory support devices have been developed to supplement pharmacological therapies and are undergoing clinical trials.