Include in assessment

• ECG – the acute LVF may be caused by ACS or an arrhythmia
• CXR
• Echocardiogram
• Catheterise and implement strict fluid balance charting 
• Serial weights
• B-type natriuretic peptide
• Troponin if ACS suspected
• ABG

Initial ABCDE approach

Follow usual ABCDE approach if critically ill.

Treatment – POND

• Position (sit up)
• Oxygen (high-flow initially; titrate to keep oxygen saturations 92-96%, consider CPAP on CCU or HDU if required)
• Nitrates in severe pulmonary oedema (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP 90-110)
• Diuretic if fluid overloaded or usually on it (e.g. furosemide 40mg IV initially)
• +treat cause

Identify and treat cause

• ACS → see notes on ACS
• Arrhythmia → see notes on arrhythmias
• Tamponade → pericardiocentesis
• Acute aortic/mitral regurgitation → valve replacement
• Hypertensive crisis → BP management
• Fluid overload → regular furosemide

Further interventions if required

• CPAP if hypoxaemic despite above interventions
• Inotropes ± intra-aortic balloon pump in ICU if in cardiogenic shock (hypotension + overload)

Long-term heart failure management

• Treat cause where possible 
• Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
• Treatments with prognostic benefit for heart failure with reduced ejection function (use all)
  • ACE inhibitor or angiotensin receptor blocker or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
  • β-blocker (e.g. bisoprolol)
  • Aldosterone antagonist (e.g. spironolactone, eplerenone) 
  • SGLT2-inhibitor (e.g. dapagliflozin, empagliflozin)
• Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) for heart failure with preserved ejection function
• Non-pharmacological treatments
  • Cardiac resynchronisation therapy device: considered if QRS significantly prolonged
  • Implantable cardioverter defibrillator: considered if risk of ventricular arrhythmias

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