Diagnosis and management of acute heart failure syndromes are described in the most recent ESC/ESICM guidelines. However, physicians dealing with these patients in their daily practice may need guidance in choosing therapeutic alternatives as soon as the dyspneic patient arrives to the emergency department. Herein, practical recommendations for the very early management of patients with acute heart failure syndromes are presented. Blood pressure- and symptom-driven strategy along with early initiation of goal-directed therapies are key take-home messages. Furthermore, early and frequent reassessment is also an imperative part of management so that adjustments in the initial therapeutic plan can be achieved in a timely fashion.