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 or physical exhaustion; 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 <90 mmHg (unless known to be usually hypotensive); signs or symptoms of hypoperfusion; haemodynamic instability; acute heart failure due to an acute coronary syndrome; recurrent 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 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.
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. Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment. This topic does not cover children or pregnant women.
History and exam
- previous cardiovascular disease
- older age
- prior episode of heart failure
- diabetes mellitus
- family history of ischaemic heart disease or cardiomyopathy
- excessive alcohol intake
- cardiac arrhythmias
- history of systemic conditions associated with heart failure
- previous chemotherapy
- valvular heart disease
- pericardial disease
- excessive salt intake
- excessive catecholamine stimulation
- abnormal thyroid function
Resham Baruah, MBBS, BSc, MRCP, PhD
Chelsea and Westminster Hospital and the Royal Brompton and Harefield NHS Trust
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
ADH declares that he has no competing interests.
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
Lisa Anderson, BSc, MB, ChB, MD
Cardiovascular Clinical Academic Group
Molecular and Clinical Sciences Research Institute
St George's, University of London
St George's University Hospitals NHS Foundation Trust
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
Oxford Heart Centre
John Radcliffe Hospital
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.
Lead Section Editor, BMJ Best Practice
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.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
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Comorbidities Editor, BMJ Best Practice
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Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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