Patients with acute pulmonary edema usually present with symptoms of left ventricular heart failure, severe respiratory distress, frothy pink or white sputum, moist pulmonary rales, and a third heart sound (S3) or fourth heart sound (S4). Patients frequently are tachycardic and hypertensive. Cardiac dysrhythmias, such as atrial fibrillation or premature ventricular contractions, are common. There may be a history of exertional dyspnea, paroxysmal nocturnal dyspnea, or orthopnea. Patients with right ventricular heart failure have dependent edema of the extremities and may have jugular venous distention, hepatic enlargement, and a hepatojugular reflex. The traditional distinction between right and left heart failure does not have great bearing on ED management, as volume overload and respiratory distress will be approached in the same manner. However, consideration must be given to patients in whom there is a suspicion of valvular pathology or acute right ventricular infarction.