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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Acute heart failure and pulmonary oedema

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Severe breathlessness, hypoxaemia, frothy sputum, shock, altered consciousness or peri-arrest physiology requires immediate ABCDE care, senior cardiology/critical-care help and treatment of the precipitant; call the resuscitation team if deterioration is imminent.

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.
  • Do not use nitrates routinely in acute heart failure. Consider IV nitrate only in selected severe hypertension, concomitant ischaemia or acute regurgitant valve disease with close BP monitoring.
  • Do not use NIV routinely; start it without delay when cardiogenic pulmonary oedema causes severe dyspnoea with acidaemia, or when conventional treatment is failing, provided there is no contraindication.
  • Do not give opiates routinely; respiratory depression, hypotension and delayed recognition of deterioration can outweigh symptomatic benefit.
  • Inotropes or vasopressors are not routine for congestion; reserve them for potentially reversible cardiogenic shock under critical-care/cardiac monitoring.
  • Before discharge, ensure clinical stability, an aetiology and management plan, specialist heart-failure input and follow-up by the specialist team within 2 weeks.

Key red flags

Cardiogenic pulmonary oedema

Acute severe dyspnoea, orthopnoea, diffuse crackles, hypoxaemia and sometimes pink frothy sputum; marked work of breathing or acidaemia signals imminent ventilatory failure.

Low-output or cardiogenic shock

Hypotension with cool peripheries, confusion, oliguria and rising lactate; rapidly assess ACS, mechanical disease, RV failure and arrhythmia.

Investigation priorities

01
ABCDE observations, continuous ECG and 12-lead ECGFirst step

Grade severity and detect ACS or arrhythmia.

Management branches

First-lineImmediate stabilisation

Suspected acute heart failure

  1. Sit upright, start ABCDE, cardiac monitoring, IV access and targeted oxygen only if hypoxaemic; obtain ECG, bloods and imaging without delaying treatment.
  2. Identify the haemodynamic phenotype and urgent precipitant, especially ACS, arrhythmia, acute valve/mechanical disease or infection.
  3. Offer IV loop diuretic and measure urine output, symptoms, BP, renal function and electrolytes.
  4. Seek early specialist heart-failure input; escalate immediately if shock, severe respiratory failure or a structural emergency is present.

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.Monitor BP, urine output, creatinine, sodium, potassium and magnesium. Give IV furosemide slowly—this SmPC limits injection to 4 mg/min, or 2.5 mg/min in advanced renal failure (serum creatinine above 442 micromol/L); rapid/high dosing increases hypotension, electrolyte-loss and ototoxicity risk.
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.Avoid in hypotension, RV infarction/preload dependence or recent PDE5-inhibitor use; severe aortic stenosis requires specialist haemodynamic judgement. Continuous BP monitoring is required.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG187: Acute heart failureUK diagnosis, IV diuresis, NIV, nitrate, shock and discharge route.
  • ESC 2021 Guidelines for acute and chronic heart failureAcute phenotype and specialist escalation context.
  • Furosemide 10 mg/mL injection SmPCLicensed IV pulmonary-oedema dose.
  • Glyceryl trinitrate infusion SmPCLicensed infusion dosing and cautions.
  • Noradrenaline 0.08 mg/mL SmPCProduct-specific central-infusion route and weight-based dosing.
  • Dobutamine 5 mg/mL SmPCLicensed adult infusion dose range and monitoring.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom