Acute heart failure

Last reviewed: 6 Sep 2022

Last updated: 11 Mar 2022

Suspect acute heart failure in any patient with: breathlessness, ankle swelling, reduced exercise tolerance, fatigue, tiredness, increased time to recover after exercise, and nocturnal cough.

Urgently assess for any signs or symptoms related to the underlying cause of acute heart failure.

Arrange immediate bedside echocardiography (requires specialist expertise) and ECG for any patient who is haemodynamically unstable (low blood pressure or shock) or in respiratory failure with suspected acute heart failure as part of looking for life-threatening causes.

Urgently identify and treat any underlying precipitants/causes of acute heart failure that must be managed immediately to prevent further rapid deterioration (while recognising that any acute heart failure is potentially life-threatening).

Request urgent cardiology/critical care support for any patient with: respiratory distress/failure; reduced consciousness; use of accessory muscles for breathing, respiratory rate >25/minute; oxygen saturation (SpO₂) <90% despite supplemental oxygen; heart rate <40 or >130 beats per minute; systolic blood pressure persistently <90 mmHg (unless known to be usually hypotensive); signs or symptoms of hypoperfusion; haemodynamic instability; acute heart failure due to an acute coronary syndrome; persistent life-threatening arrhythmia.

For any patient with suspected heart failure always record and interpret a 12-lead ECG; monitor this continuously.

Also always order a chest x-ray, N-terminal-proB-type natriuretic peptide (NT-proBNP), or BNP as well other standard blood tests, and echocardiography to establish the presence or absence of cardiac abnormalities.

Determine acute drug treatment based on the patient’s clinical presentation, including haemodynamic status and the presence of shock; drug treatment options include vasoactive drugs, diuretics, and vasodilators.

After stabilisation, start an oral diuretic if the patient has symptoms or signs of congestion, or switch from an intravenous to an oral diuretic once a patient who was started on an intravenous diuretic in the acute phase is euvolaemic.

Plan subsequent treatment based on measurement of the patient’s left ventricular ejection fraction using echocardiography and their level of symptoms.

Ensure the patient has input from the heart failure specialist team within 24 hours of admission to hospital.

Definition

Heart failure is defined clinically as a syndrome in which patients have symptoms and signs resulting from an abnormality of cardiac structure and/or function.[1] Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.[1] This topic does not cover children or pregnant women.

History and exam

Key diagnostic factors

breathlessness
peripheral oedema
reduced exercise tolerance
fatigue
cold extremities
elevated jugular venous pressure
risk factors
displaced apex beat
gallop rhythm (third heart sound)

Full details

Other diagnostic factors

nocturnal cough
wheezing
dizziness
confusion
loss of appetite
nocturnal ischaemic pain
ascites
central cyanosis
narrow pulse pressure
altered mental status
oliguria
delayed capillary refill time
pulmonary crepitations
dullness to percussion/decreased air entry in lung bases

Full details

Risk factors

previous cardiovascular disease
older age
prior episode of heart failure
diabetes mellitus
family history of ischaemic heart disease or cardiomyopathy
excessive alcohol intake
smoking
cardiac arrhythmias
history of systemic conditions associated with heart failure
previous chemotherapy
medication
hypertension
valvular heart disease
pericardial disease
myocarditis
excessive salt intake
excessive catecholamine stimulation
abnormal thyroid function

Full details

Diagnostic investigations

1st investigations to order

ECG
chest x-ray
natriuretic peptides
troponin
full blood count
urea, electrolytes, and creatinine
glucose and HbA1c
liver function tests
thyroid function tests
C-reactive protein
D-dimer
echocardiography

Full details

Investigations to consider

venous or arterial blood gas
blood tests screening for myocarditis
bedside thoracic ultrasound

Full details

Treatment algorithm

ACUTE

haemodynamically unstable: hypotensive (systolic BP <90 mmHg) or other signs of cardiogenic shock

haemodynamically unstable: hypertensive crisis

haemodynamically stable

ONGOING

acute episode stabilised: LVEF ≤40%

acute episode stabilised: LVEF 41% to 49%

acute episode stabilised: LVEF ≥50%

Contributors

Expert advisers

Resham Baruah, MBBS, BSc, FRCP, MSc, PhD

Consultant Cardiologist

Heart Failure Lead

Chelsea and Westminster Hospital and the Royal Brompton and Harefield NHS Trust

London

Biography

RB was a specialist advisor to the National Institute for Health and Care Excellence guideline on chronic heart failure in adults.

Disclosures

RB has received honorarium/speaker fees from Novartis and Boehringer Ingleheim.

Adam D. Hartley, MBBS, BSc, MRCP

Wellcome Trust Clinical Research Fellow

Imperial College London

Specialist Registrar in Cardiology

Imperial College Healthcare NHS Trust

London

Disclosures

ADH declares that he has no competing interests.

Acknowledgements

Best Practice would like to gratefully acknowledge the previous expert contributor, whose work is retained in parts of the content:

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

Peer reviewers

Lisa Anderson, BSc, MB, ChB, MD

Consultant Cardiologist

Cardiovascular Clinical Academic Group

Molecular and Clinical Sciences Research Institute

St George's, University of London

St George's University Hospitals NHS Foundation Trust

London

Disclosures

LA was deputy chair for the British Society of Heart Failure clinical advisory board for tafamidis, undertook consultancy services for tafamidis (Pfizer), received a research grant from Pfizer, was on the clinical advisory board for dapagliflozin (AstraZeneca), and received lecture fees from the British Society of Cardiology/AstraZeneca and Pfizer.

James Gamble, BM, BCh, DM, FRCP

Consultant Cardiologist

Oxford Heart Centre

John Radcliffe Hospital

Oxford

Disclosures

JG has been reimbursed for delivering educational meetings by: Novartis, the manufacturer of sacubitril/valsartan; Boerhinger Ingelhiem, the manufacturer of empagliflocin; AstraZeneca, the manufacturer of dapagliflozin; and Medtronic, the manufacturer of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices. He has been supported to attend educational meetings by Abbott, Medtronic, and Boston Scientific, who all manufacture ICD and CRT devices. All of these companies produce drugs or devices related to the treatment of heart failure.

Editors

Susan Mayor,

Lead Section Editor, BMJ Best Practice

Disclosures

SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including the National Institute for Health and Care Excellence, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, the National Confidential Enquiry into Patient Outcome and Death, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.

Annabel Sidwell,

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Rachel Wheeler,

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello,

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell,

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Expert advisers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Leeds

Disclosures

AL is Associate Clinical Director of NIHR Leeds In-Vitro Diagnostics Co-operative, Co-Chair of UK Kidney Research Consortium Renal Clinical Study Group, Member of Kidney Research UK Research Grant Committee, Committee Member of NICE Kidney Injury Clinical Guideline Update 2018-20, Committee Member of NICE Diagnostic Assessment for Point of Care Creatinine Testing 2018-19. AL attended the Acute Dialysis Quality Initiative Meeting in San Diego 2018 (accommodation expenses); AL was a speaker at the AKI & CRRT Conference in San Diego 2019 (travel and accommodation expenses), the AKI Conference in Coventry 2019 (travel expenses), and the NIHR AKI and Sepsis Meeting in Leeds 2019 (no expenses).

Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

Disclosures

MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, & Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

Disclosures

RAE has given lectures for non-promotional industry-led sessions on COPD management, including for GSK and Chiesi for individual payment and travel expenses totalling <£2,000.

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

Disclosures

GR has been paid for advisory board meetings with the following companies: Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Bayer. GR has received lecture fees from Safoni Aventis, Abbott Diabetes UK, Lilly Diabetes, Novonordisk, Napp Pharmaceuticals Ltd.

Sotiris Posporelis, MD, MRCPsych

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

Disclosures

SP declares that he has no competing interests.

Asangaedem Akpan, MPH, FRCP

Consultant Geriatrician

Liverpool University Hospitals NHS Foundation Trust

Visiting Professor

University of Cumbria

Carlisle

Honorary Clinical Associate Professor

University of Liverpool

Liverpool

Disclosures

AA declares that he has no competing interests.

Peer reviewers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare virtual conference in November 2020, for which he received no fee. MP has accepted speaker fees and/or travel expenses to deliver lectures from: University of East Anglia, Leicester University (speaker fees only); Astellas Pharma Ltd (speaker fees and travel expenses). MP has accepted travel expenses from Newton Europe to present a joint project conducted by his main employer (Norfolk and Norwich University Hospitals NHS Trust) and Newton Europe at the NHS Confederation conference (Manchester 2018).

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Acute heart failure

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

haemodynamically unstable: hypotensive (systolic BP <90 mmHg) or other signs of cardiogenic shock

haemodynamically unstable: hypertensive crisis

haemodynamically stable

acute episode stabilised: LVEF ≤40%

acute episode stabilised: LVEF 41% to 49%

acute episode stabilised: LVEF ≥50%

Contributors

Expert advisers

Resham Baruah, MBBS, BSc, FRCP, MSc, PhD

Biography

Disclosures

Adam D. Hartley, MBBS, BSc, MRCP

Disclosures

Acknowledgements

Peer reviewers

Lisa Anderson, BSc, MB, ChB, MD

Disclosures

James Gamble, BM, BCh, DM, FRCP

Disclosures

Editors

Susan Mayor,

Disclosures

Annabel Sidwell,

Disclosures

Rachel Wheeler,

Disclosures

Julie Costello,

Disclosures

Adam Mitchell,

Disclosures

Expert advisers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Disclosures

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Disclosures

Martin Cowie, MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Disclosures

Rachael Evans, MBChB, FRCP (UK), PhD

Disclosures

Gerry Rayman, MD, FRCP

Disclosures

Sotiris Posporelis, MD, MRCPsych

Disclosures

Asangaedem Akpan, MPH, FRCP

Disclosures

Peer reviewers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Disclosures

Differentials

Guidelines

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