Table of Contents
Initial ABCDE approach
Follow usual ABCDE approach if critically ill.
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
Treatment – PODMAN
- Position (sit up)
- Oxygen (high-flow initially; titrate to keep oxygen saturations 92-96%, consider CPAP on CCU or HDU)
- Diuretic if fluid overloaded or usually on it (e.g. furosemide 40mg IV initially)
- Morphine if patient anxious/distressed (e.g. morphine 2-4mg IV)
- Antiemetic if nauseous or giving morphine (e.g. metoclopramide 10mg IV)
- Nitrates in severe pulmonary oedema (GTN infusion if SBP >110, or 2 puffs GTN spray if SBP 90-110)
Identify and treat cause
- ACS → PCI
- 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