It’s 2 a.m. and the pager jolts you from a deep sleep. It’s the emergency department. “We have a 68-year-old male, shortness of breath, looks like acute heart failure,” the resident says over the phone. You pull yourself out of the call room bed. Another night, another case of acute decompensated heart failure. It’s one of the most common reasons for admission, yet it always presents its own set of challenges.