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.

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]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.[1]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com This topic does not cover children or pregnant women.