Questionnaire/history:

Breathlessness?

Orthopnoea?

Paroxysmal nocturnal dyspnoea?

Coughing (rarely producing frothy, blood-stained sputum)?

Peripheral oedema?

Lethargy?

Past medical history?

Current medication?

Drug allergies?

Examination:

Elevated JVP?

Inspiratory crackles at lung bases +/- wheeze?

Hepatosplenomegaly?

Ascites?

Peripheral oedema?

Gallop rhythm?

Investigations:

ECG?

CXR?

BNP?

- BNP < 100ng/litre?

- NT-proBNP < 300 ng/litre?

Troponin?

D-dimer if PE suspected?

FBC?

U&E?

LFT?

TFT?

Diagnosis:

ACS?

Hypertensive crisis?

Arrhythmia?

Mechanical cause (eg complication of ACS (eg free wall rupture, acute mitral regurgitation), acute valve incompetence, chest trauma or cardiac intervention)?

Pulmonary embolism?

Infection?

Tamponade?

Classification:

- Acutely decompensated HF?- Acute pulmonary oedema?

- Isolated RV failure (usually caused by ACS with RV involvement or PE)?- Cardiogenic shock?

Management:

Oxygen (if SpO2 < 90%)?

Opiates if severe pain or anxiety or in a palliative setting?

IV Furosemide 1-2x current oral daily dose or 20-40mg IV if diuretic naive?

(Large falls in eGFR (?5-25%) acceptable as long as concomitant evidence of improvement)

S/L nitrate considered if acute pulmonary oedema?Oral therapy continued unless haemodynamic instability, severely impaired renal function or hyperkalaemia?

Reference(s):

European Society of Cardiology (ESC): 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure