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welcome back to part two of congestive heart failure in this section well talk about investigations and treatment of heart failure in the emergency department depending on the severity of the patients heart failure we often have to investigate and treat at the same time well split it up and discuss investigation first the different modalities include ecg chest x-ray ultrasound and labs in terms of ecg were really looking for any signs of ischemia or infarct chest x-ray is extremely important in the patients with left-sided heart failure there are multiple abnormalities we can see in chess x-ray one of the early signs of chf is a phenomenon known as vascular redistribution on the chest x-ray in a normal chest x-ray upper lobe vessels are usually much less prominent than lower lip vessels that is because the lower lip vessels carry more pulmonary blood flow in patients with chf as the pulmonary venous pressure increases the lower low vessels become more constricted that means that m