Synopsis
Recognise the acute heart-failure phenotype, relieve congestion safely and escalate respiratory failure, shock or a reversible cardiac cause through the NICE route.
- Acute heart failure is a syndrome: define congestion, perfusion and blood pressure while searching for ACS, arrhythmia, valve/mechanical disease, infection, uncontrolled hypertension and medicine or renal triggers.
- Offer IV loop diuretic therapy for acute heart failure; if the person already takes a loop diuretic, NICE advises an initial IV dose higher than their admission oral dose, then titrate to response.
- Give oxygen for hypoxaemia, not routinely to a normoxaemic patient; monitor saturation and blood gases when respiratory failure is severe.
Key red flags
Acute severe dyspnoea, orthopnoea, diffuse crackles, hypoxaemia and sometimes pink frothy sputum; marked work of breathing or acidaemia signals imminent ventilatory failure.
Investigation priorities
Grade severity and detect ACS or arrhythmia.
Management branches
Suspected acute heart failure
- Sit upright, start ABCDE, cardiac monitoring, IV access and targeted oxygen only if hypoxaemic; obtain ECG, bloods and imaging without delaying treatment.
- Identify the haemodynamic phenotype and urgent precipitant, especially ACS, arrhythmia, acute valve/mechanical disease or infection.
Key medicines
Furosemide IVIf loop-diuretic naive, the cited SmPC starts 20–40 mg IV for pulmonary oedema; if diuresis does not increase, it permits a repeat after 30–60 minutes, if necessary at twice the dose. If already taking a loop diuretic, NICE advises an initial IV dose higher than the pre-admission oral dose, followed by response- and renal-function-led adjustment.
Glyceryl trinitrate IVWhen specifically selected for unresponsive congestive/acute left-sided heart failure, the cited SmPC starts 20–25 micrograms/min IV by infusion pump; reduce to 10 micrograms/min or increase by 20–25 micrograms/min every 15–30 minutes to response. Its usual overall range is 10–200 micrograms/min.