Lightning Learning: Acute Heart Failure

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STOP!

Heart failure is a condition that can be caused by heart muscle dysfunction (systolic or diastolic), arrhythmias, valvular dysfunction or rarer causes.⁽¹⁾

Patients admitted with acute heart failure have a mortality of up to 10%. Following discharge, mortality increases up to 50% over the next 12 months.⁽²⁾

With this in mind, it is pertinent to establish ongoing treatment plans with patients as they are highly prone to deterioration. It can present as new-onset heart failure without any known cardiac dysfunction or as acute decompensation of chronic heart failure.

Symptoms include:

• Progressive dyspnoea
• Chest pain
• Orthopnoea
• Oedema (ankle/leg/sacral)
• Fatigue

LOOK

History:

Consider asking about… Pre-existing illness? Infective symptoms? Duration? Exercise tolerance? Orthopnoea, paroxysmal nocturnal dyspnoea? Chest pain? Compliance with medication?

Investigations:

ECG (serial ECGs if ischaemic changes); Bloods (consider serum BNP), CXR. Bedside echocardiogram is the key investigation to confirm the diagnosis (refer to your local guideline⁽²⁾ for ECHO features).

Management:

• Perform A-E assessment of the patient.
• Stepwise approach to medical management in acute setting, e.g. Oxygen, IV furosemide (bolus/infusion), IV GTN. Treat co-existing illness, e.g. pneumonia with antibiotics. Input/output monitoring, e.g. patient weight, urine output.
• When medical management not helping, discuss with senior doctor in Resus to initiate CPAP⁽³⁾ (refer to local guideline). Consider escalation status.
• Liaise with Cardiology for admission and ongoing management.

LEARN

Chest X-Ray Findings:

A good mnemonic to remember these principles is ABCDE…⁽⁴⁾

1. Alveolar oedema (bat wing opacities)
2. Kerley B lines
3. Cardiomegaly
4. Dilated upper lobe vessels
5. Pleural effusion

References:

1. Acute heart failure: diagnosis and management (NICE)
2. Local Cardiology Guidelines (UHL)
3. Boussignac CPAP system: indications and instructions for use in the Emergency Department (UHL)
4. Bat wing opacities (lungs) (Radiopaedia)