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Acute heart failure
Sit them up, treat the hypoxia, offload the fluid — and find out why it happened. Recognise the wet, breathless patient, start oxygen and IV diuretics, use CPAP if they're tiring, and look for the trigger: ischaemia, arrhythmia, hypertension, valve disease, infection or missed tablets. Built for revision, not live patient decisions.
Settle them, and check the basics
oxygen · upright · diureticRed flags — what each should make you think
Find the trigger: the CHAMP causes are ACS, Hypertension, Arrhythmia, Mechanical (valve or septal) and Pulmonary embolism. Infection, anaemia, thyroid disease, missed tablets and NSAIDs are also common. Treating the trigger is often what really fixes the failure.
The first actions
- ↑Sit upright
- O₂Oxygen
- FuIV furosemide
- NIVCPAP if needed
- ECGECG + monitor
- UOFluid balance
Understand the patient
recognise · trigger · typeRecognise it
- Breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, frothy pink sputum
- Bilateral crackles, raised JVP, peripheral oedema, third heart sound
- CXR: upper lobe diversion, interstitial oedema (Kerley B lines), bat-wing shadowing, effusions, cardiomegaly
- Natriuretic peptide: in the acute setting, NT-proBNP below 300 ng/L (or BNP below 100) makes heart failure unlikely
What NICE says about the drugs
- Do not routinely give opiates
- Do not routinely give nitrates — consider them with concomitant ischaemia, severe hypertension, or regurgitant aortic/mitral disease (watch BP)
- Continue beta-blockers unless HR below 50, second- or third-degree AV block, or shock
- Inotropes/vasopressors only for shock or potentially reversible cardiogenic shock, in a cardiac/critical care setting
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
SBP below 90 with poor perfusion: cold, mottled, confused, oliguric, high lactate.
Clinical + echo.
Cardiology and ITU now. Treat the cause (emergency PCI for ACS). Inotropes/vasopressors and mechanical support under specialist care. Diuretics with care.
Chest pain, ST changes, troponin rise disproportionate to the failure.
ECG, troponin, echo (regional wall motion).
ACS pathway (see ACS page); STEMI → PPCI.
Abrupt severe breathlessness with very high BP; may be euvolaemic (fluid redistribution rather than overload).
Clinical, CXR.
CPAP and IV nitrates (titrated infusion) are the mainstay; diuretics if overloaded. Look for renal artery stenosis if recurrent.
Acute mitral regurgitation (papillary rupture, endocarditis) or critical aortic stenosis. New loud murmur, flash oedema, shock.
Urgent echo.
Cardiology and cardiothoracic surgery. Be careful with nitrates in severe aortic stenosis.
Hypotension, raised JVP, muffled heart sounds, clear lungs, pulsus paradoxus. Cancer, recent cardiac surgery, uraemia.
Bedside echo.
Pericardiocentesis; avoid diuretics and nitrates.
Investigate — what to order, when, and what it tells you
test with a question in mindNatriuretic peptide
ECG + troponin
CXR
Bloods
Echo
How the plan comes together
disposition · handovercardiology / medical ward
Responding to oxygen and diuretics. Daily weights, U&E, fluid balance. Specialist heart failure team input, echo, and start or optimise disease-modifying drugs before discharge.
CCU / ITU
Shock, respiratory failure needing CPAP/ventilation, ACS, or arrhythmia needing intervention.
Hand over: trigger, diuretic dose and response, weight, U&E, escalation plan.
Oxygen, sit them up, IV diuretics, CPAP if tiring — then find the CHAMP cause. Ask about missed tablets and NSAIDs: they cause more readmissions than you'd think. Nicely done getting here.
Clerking template
copy or downloadAcute heart failure — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 12 knownFrequently asked questions
quick answersWhat are the red flags for acute heart failure?
- SBP below 90, cold peripheries — think cardiogenic shock
- Chest pain or ECG changes — think ACS-triggered failure
- Very fast or very slow rhythm — think arrhythmia-triggered
- BP very high with pulmonary oedema — think hypertensive (flash) pulmonary oedema
- New loud murmur — think acute valve lesion
- RR above 30, SpO₂ below 90 despite O₂, acidotic — think needs CPAP / ITU
- Raised JVP, quiet heart, low BP — think tamponade (mimic)
What is the initial management of acute heart failure?
- Sit upright — legs down if possible
- Oxygen — titrate to SpO₂ 94–98% (88–92% if at risk of hypercapnia)
- IV furosemide — if already on a loop diuretic, give at least their usual oral dose IV; review response
- CPAP if needed — severe breathlessness with acidaemia, or not improving
- ECG + monitor — ACS, arrhythmia
- Fluid balance — catheter if strict monitoring needed; daily weights
Always alongside senior support and your local guideline.
What diagnoses must you not miss in acute heart failure?
- Cardiogenic shock — cold · wet · low BP
- ACS-driven failure — ischaemia
- Hypertensive pulmonary oedema — sudden · BP very high
- Acute valve lesion — new murmur
- Tamponade (mimic) — raised JVP · clear lungs
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for acute heart failure?
- Natriuretic peptide — Low level rules out HF; high level supports it.
- ECG + troponin — ACS, arrhythmia as triggers.
- CXR — Oedema, effusions, cardiomegaly, alternative diagnoses.
- Bloods — U&E (before and during diuretics), FBC, CRP, LFT, TFT, glucose, Mg.
- Echo — Within 48 h of admission (NICE) — urgently if shock or a valve problem is suspected.
Admit or discharge: how is the plan decided for acute heart failure?
- Cardiology / medical ward — Responding to oxygen and diuretics. Daily weights, U&E, fluid balance. Specialist heart failure team input, echo, and start or optimise disease-modifying drugs before discharge.
- Ccu / itu — Shock, respiratory failure needing CPAP/ventilation, ACS, or arrhythmia needing intervention.
Is there a clerking template for acute heart failure?
Yes — there is a clerking template for acute heart failure on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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