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Acute Heart Failure

NICE guidelines [CG187] Acute heart failure: diagnosis and management. Last updated: Nov 2021.

Background Information

There are 2 main types of acute heart failure:
  • De novo acute heart failure: sudden onset of heart failure in someone with no history or diagnosis of heart failure
  • Acute decompensated chronic heart failure: acute worsening of symptoms in someone with established chronic heart failure

  • Acute coronary syndrome - most common and important
  • Acute valvular disease
  • Acute myocarditis
  • Arrhyhtmias

  • Acute infections (e.g. respiratory tract infection, UTI)
  • Non-adherence with medication / dietary restrictions
  • Atrial fibrillation and other arrhythmias
  • Acute coronary syndrome
  • Uncontrolled hypertension
  • Anaemia

Main complications are:
  • Haemodynamic instability (can cause cardiogenic shock)
  • Pulmonary congestion
  • End-organ hypoperfusion

Diagnosis

Pulmonary and systemic congestion are the main presenting features:
  • Pulmonary congestion (from left ventricular failure)
    • Sudden onset dyspnoea and orthopnoea
    • Cough +/- pink frothy sputum
 
  • Systemic congestion (from right ventricular failure)
    • Peripheral oedema
    • Weight gain

Pulmonary and systemic congestion are the main presenting features:
  • Pulmonary congestion (from left ventricular failure)
    • Bi-basal crackles
    • Cardiac wheeze
    • S3 gallop rhythm
 
  • Systemic congestion (from right ventricular failure)
    • Raised JVP
    • Peripheral oedema
    • Ascites
    • Congestive hepatopathy

Measure serum BNP or NT-proBNP level to rule out heart failure

Heart failure is unlikely if:
  • BNP < 100 ng/L
  • NT-proBNP < 300 ng/L

Confirmatory test: trans-thoracic echocardiogram
  • If de novo acute heart failure → perform within 48 hours of admission

A standard heart failure workup includes:
  • Chest X-ray
  • ECG
  • Blood tests (FBC, LFT, U&E, TFT, lipid profile, HbA1c)
  • Urinalysis
  • Peak flow or spirometry

It is common in practice to diagnose acute heart failure with a chest X-ray to initiate management, before BNP / NT-proBNP results are available.

Main chest X-ray findings in heart failure are (ABCDE):

  • A: Alveolar oedema (perihilar bat wing opacities - from fluid accumulation in alveolar spaces)
  • B: Kerley B lines (short horizontal lines at peripheral lung margins - from interstitial oedema)
  • C: Cardiomegaly (>50% of thoracic width) (NB heart size can ONLY be assessed in a PA chest X-ray)
  • D: Dilated upper lobe vessels (↑ left atrial pressure → redistribution of blood to upper lobes)
  • E: Pleural effusion (typically bilateral transudative effusion)

Management

1st line: IV loop diuretic (furosemide 40-120 mg / bumetanide 1-3 mg) - to relieve congestive symptoms

Add-on therapy:
  • IV nitrates if there is:
    • Concomitant myocardial ischaemia, or
    • Severe hypertension, or
    • Aortic or mitral regurgitation
 
  • Ventilatory support
    • CPAP can be used in severe cardiogenic pulmonary oedema
    • Endotracheal intubation and mechanical ventilation - last resort
 
  • If cardiogenic shock → consider inotropes (e.g. dobutamine) or vasopressors (e.g. noradrenaline, adrenaline)

Do not routinely discontinue long-term heart failure medications, unless there are clear contraindications:

  • Beta blocker should be stopped if HR <50 bpm / shock / 2nd or 3rd degree AV block
  • ACE inhibitors should only be stopped if there is AKI / shock

References

NICE guideline Acute heart failure: diagnosis and management​​​​​​​
Author: Noah Thomaidis, Adams Lau
Reviewer:
Last edited: 18/09/25