Introduction: Acute heart failure (AHF) is a life-threatening medical condition requiring urgent evaluation and treatment. This is the first clinical audit to evaluate the adherence of clinicians to international guidelines for management of AHF. Hypothesis: Development of local guidelines and adherence to them by clinicians will improve quality of care and ensure patient safety. Methods: This was a retrospective clinical audit conducted from January to December 2016. Two-hundred files of patients admitted to Nasser Hospital (n = 74) and Al-Shifaa Hospital (n = 126) were reviewed and compared to the European Society of Cardiology (ESC) Guidelines 2016. Results: The mean age of our sample was 66 ± 13 years. Fifty percent of patients were females and 96% had co-morbidities including hypertension, DM and heart disease. Shockingly vital signs were poorly documented (51% temperature, 59% pulse rate, 71.5% respiratory rate and 13% blood pressure) and SpO2 in only 69.5%. From the available data, at time of presentation, 40% had a high blood pressure, 37.7% had an SpO2 < 90%, 50.5% were anemic and 33% had leukocytosis. ECG, chest x-ray and echocardiography were done in 94.5%, 48.5% and 45%, respectively. Creatinine and urea levels were obtained in 93.5% and 89% with elevated values observed in 45.5% and 96.6%, respectively. Electrolytes (Na+ and K+) were measured in 63% of cases, glucose level in 88% but only 10% had arterial blood gases measured and 2.5% TSH level. It was found that 21.4% had hyperkalemia and 77.3% had hyperglycemia. Cardiac troponins were only done in 5.5% while 66.5% of patients had CKMB measured and BNP level wasn't utilized at all. Although 37.7% of patients had an SpO2 < 90%, it was surprising that only 12.5% received oxygen therapy. Intravenous furosemide was used in 69% and opiates were only administered to 30%. Vasodilators were given to 46.5% where systolic blood pressure was > 90 mmHg in 89.1% of them. Beta blockers (BB) were used in 57% (70.2% bisoprolol, 29.8% carvedilol). It was noted that BB were given to 2 hypotensive patients, which is not consistent with ESC guidelines. Digoxin 0.25 mg was given in 28.5% of which 53.4% had atrial fibrillation. Venous thromboembolism prophylaxis was administered to 70%. Conclusions: The results of this audit reflect the fact that the management of AHF does not comply with the ESC guidelines. This could be attributed to the lack of local guidelines and unawareness of international guidelines. Furthermore, the poor medical record and registry systems cause loss of data and physician orders which in turn causes more deviation from the recommended guidelines. Therefore, there is an urgent need for the development of local guidelines as well as promotion of knowledge of evidence-based practice among clinicians. In addition, the current documentation system should be improved as soon as possible to facilitate the process of evaluating the clinical practice in future.