Impressive advances have been made in recent years in the treatment of chronic ambulatory heart failure (HF) with use of novel therapies for heart failure with reduced ejection fraction (HFrEF) estimated to add 6.3 additional life-years for a 55-year-old patient [1]. Identification of sodium glucose cotransporter 2 (SGLT2) inhibitors as a beneficial therapy for heart failure with preserved ejection fraction (HFpEF) is also likely to translate into improved clinical outcomes for future HFpEF patients [2]. However, strategies for improving outcomes for acute heart failure patients remain elusive, as readmission rates remain high and inpatient length of stays are frequently long, with minimal change over the past decade. Despite acute HF being one of the most common indications for inpatient care in Australia, there are very few randomised controlled trials in acute HF to guide treatment. It is notable that in the ESC 2021 heart failure guidelines, the section for acute HF management contains 15 recommendations; however, of these, only a single recommendation for thromboprophylaxis against deep venous thrombosis has level A level of evidence, and nine of these 15 recommendations have level C level of evidence (i.e., based predominantly on expert opinion) [3]. In this context, we often need to turn to observational studies to guide management of acute HF.