Sooner or later all heart failure patients will present to the emergency department for medical attention. The American demographic trend of a skyrocketing elderly population coupled with the current heart-failure epidemic means that strategies optimizing emergency department care of heart failure are needed. Safe and effective management has the potential to decrease hospitalizations and intensive care unit admissions, prevent readmissions, and improve the quality of life in the heart-failure patient, as well as relieving some of the economic burden of heart-failure management from the U.S. medical care system. The emergency department observation unit provides a successful venue for the management of decompensated heart failure, and nesiritide offers the promise of shorter hospitalizations, improved quality of life, and better symptom resolution than standard therapy.