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