Profile the patient as warm/cold and wet/dry. Warm-wet: IV loop diuretic plus vasodilator if SBP > 110 and CPAP/NIV for pulmonary oedema. Cold: cardiogenic shock pathway. Always find the trigger.
At the bedside
Timed steps- 1
Stabilise
0-10 minSit up, O2 to SpO2 > 90%, CPAP/NIV if RR > 25 or SpO2 < 90%. ECG, troponin, NT-proBNP, echo.
- 2
Profile
0-30 minWarm-wet (commonest), cold-wet, cold-dry, warm-dry.
- 3
Find the trigger
0-60 minACS, hypertensive emergency, arrhythmia, mechanical cause (valve rupture, VSR), PE, infection, tamponade, non-adherence, NSAIDs, renal failure, anaemia, thyroid.
- 4
Loop diuretic
CongestedFurosemide 20-40 mg IV if naïve, or 1-2 × the oral daily dose. Spot urine Na < 50-70 mmol/L at 2 h or urine < 100-150 mL/h at 6 h: double the dose; then add a thiazide or acetazolamide.
- 5
Vasodilator
SBP > 110GTN 10-20 mcg/min IV, titrate to 200 mcg/min.
- 6
Shock
SBP < 90 / coldCardiogenic shock pathway (module 3); no vasodilators.
- 7
Guideline therapy
Before dischargeACE-i/ARNI, beta-blocker, MRA, SGLT2i with rapid up-titration.
Decongestion
Furosemide
- Dose
- 20-40 mg (naïve) or 1-2 × daily oral dose
Hypertensive pulmonary oedema
Glyceryl trinitrate (nitroglycerin)
- Dose
- 10-20 mcg/min, up to 200 mcg/min
- Preparation
- 50 mg in 50 mL = 1000 mcg/mL
- Worked example
- 20 mcg/min × 60 = 1200 mcg/h ÷ 1000 = 1.2 mL/h
Haemodynamic profiles
| Profile | Signs | Treatment |
|---|---|---|
| Warm-wet | Congested, perfused | Diuretic ± vasodilator |
| Cold-wet | Congested, cold, oliguric, confused | Vasopressor/inotrope first, then diuretic |
| Cold-dry | Hypoperfused, not congested | Cautious fluid; consider inotrope |
| Warm-dry | Compensated | Optimise oral therapy |
Calculators for this topic
References
- 1
- 2
Acute heart failure
Step 1 of ~4
Sit up, O2, CPAP/NIV if distressed; ECG, echo, BNP
Based on McDonagh TA, Metra M, Adamo M, et al. Educational use; follow local protocol.
Evidence
- ESC HF 2021: NIV for respiratory distress; loop diuretics with early natriuresis check; vasodilators if SBP > 110; routine opioids not recommended.
- ESC HF 2023 update: rapid initiation and up-titration of guideline therapy before and soon after discharge.
🇮🇳 India notes
- Rheumatic mitral stenosis with AF is still a common cause of pulmonary oedema in India: control rate and diurese; consider balloon valvotomy.
- Peripartum cardiomyopathy: see module 30.
References
- 1
- 2
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.