A patient presenting with suspected heart failure (HF) should be assessed and treated quickly with a diagnosis made as soon as possible. Flash pulmonary oedema should be treated straight away. 

A patient presenting with acute HF typically shows dyspnea and/or increased peripheral oedema. Questions should be asked about tightening in the chest, air hunger, difficulty in breathing; signs include crackling in the lungs and wheezing. There may be a complaint of fatigue and coughing particularly on exertion. The patient may complain of needing more pillows in order to sleep comfortably at night or of experiencing paroxysmal nocturnal dyspnea.

A detailed history and examination is advisable to assess the severity of heart failure (HF) in all but the most unstable patients particularly those in severe respiratory distress.

Patients with acute coronary syndrome and HF

Where there is ST elevation myocardial infarction and signs of congestive HF a coronary angiography and revascularisation are required.

Treatment 

Emergency Department treatment starts with the standard ABC (airway, breathing, circulation) evaluations to identify those in severe respiratory distress and potential respiratory failure. Blood tests should be taken and urine output should be evaluated and monitored. Potential hypertension should be evaluated. Primary goals include support of oxygen intake, ventilation and hemodynamic stabilisation. A patient in acute respiratory distress may need intubation to secure an airway. Non-invasive ventilation should be the first option providing the patient is able to cooperate and providing the ED technician establishes that the patient is able to speak. Patients unable to speak even a one word sentence should be considered for intubation. All patients will likely benefit from oxygen administration. 

Testing

An electrocardiogram (ECG) should be taken on all patients presenting with a suspicion of HF as soon as possible to ascertain the type of treatment and future management needed. A patient with dyspnea and underlying cardiac arrhythmia or ischemia can be referred for early cardiology treatment.

In a patient presenting with dyspnea an x-ray can determine other causes such as pneumonia or chronic obstructive pulmonary disease, or can provide evidence of cardiomegaly or signs of pulmonary oedema with central vascular congestion which may support a diagnosis of HF.

Ultrasound testing is increasing in the diagnosis of HF but should not be used on a patient with acute dyspnea due to the discomfort which would be experienced by the patient in a supine position. 

When a patient presents with a new case of suspected HF use a single measurement of serum natriuretic peptides (B-type or N-terminal pro-B-type with thresholds of:

• BNP less than 100ng/litre

• NT-pro-BNP less than 300ng/litre

To rule out a diagnosis of HF.

Where there are raised natriuretic peptide levels, a transthoracic Doppler 2D echocardiogram should be performed to establish the presence or otherwise of cardiac normalities.

Patient already taking beta-blockers

In a patient with acute heart failure already on beta-blockers, continue the beta-blocker treatment providing:

• their heartbeat is not less than 50 bpm, 

• they are not in second or third degree atrioventricular shock, or block

Discharge following an acute phase of HF and subsequent management should follow the NICE guidelines on chronic heart failure.