March 2022

This month we are going to talk acute heart failure – NICE update their guidance on management of acute heart failure November 2021, admittedly there is nothing ground-breaking in the guidance so we thought it would be a great time to recap how we manage these patients in the Emergency Department. Overview | Acute heart failure: diagnosis and management | Guidance | NICE

At times we will also refer to the ESC guidelines for heart failure management published August 2021 – which quite frankly is a beast of a document weighing in at 128 pages long!!! academic.oup.com

Definition Acute Heart Failure: 

Not a single pathology but a syndrome consisting of symptoms (Breathlessness, ankle swelling and fatigue) that may be accompanied by signs (raised JVP, peripheral oedema and pulmonary crackles).  It is due to either structural or functional problems affecting the heart leading to increased intracardiac pressures and/or inadequate cardiac output either at rest or on exertion. (From the ESC)

 In hospital mortality for acute heart failure is 4-10%, has a 14% 30-day mortality and post discharge 1 year mortality of up to 25%.

Initial diagnosis assessment and monitoring

So, what do NICE suggest for these patients: 

• Take a history, perform a clinical examination and undertake standard investigations – for example, electrocardiography, chest Xray and blood tests – I will always do a ABG in these patients.
• In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (Btype natriuretic peptide [BNP] or Nterminal proBtype natriuretic peptide [NTproBNP]) and the following thresholds to rule out the diagnosis of heart failure:
• BNP less than 100 ng/litre
• NTproBNP less than 300 ng/litre

If these are raised, you should be thinking about getting a transthoracic ECHO done to look for abnormalities. Let skip over to what the ESC guideline says about the BNP acutely 

– ‘Plasma NP levels should be measured if the diagnosis is uncertain, and a point-of-care assay is available. Normal concentrations of NPs make the diagnosis of AHF unlikely……. However, elevated NP values are associated with a wide range of cardiac and non-cardiac conditions Low concentrations can be detected in some patients with advanced decompensated end-stage HF, obesity, flash pulmonary oedema or right sided AHF. Higher levels can be found in the patients with concomitant AF and/or reduced renal function’

The ESC guideline has a great table we reference several times during the podcast, it splits heart failure into four categories and is worth a read:

Pharmacological Treatment: 

• Offer intravenous diuretic therapy to people with acute heart failure. Start treatment using either a bolus or infusion strategy. Remember that for people already taking a diuretic, consider a higher dose of diuretic than that on which the person was admitted unless there are serious concerns with patient adherence to diuretic therapy before admission. If already on diuretic start with an initial I.V.  dose of furosemide, or equivalent dose of bumetanide or corresponding to 1–2 times the daily oral dose taken by the patient before admission. If the patient was not on oral diuretics, a starting dose of 20–40 mg of furosemide IV.  

There is quite a list of DO NOTs in the NICE guidance 

• Do not routinely offer opiates to people with acute heart failure. 

• Do not routinely offer nitrates to people with acute heart failure. You can however consider them in certain circumstances – ischaemia, severe hypertension (it also says that you can use them in aortic or mitral regurg – but I’d like my friendly cardiology colleague to help me make that call!). if using you must monitor closely in level 2 setting (these patients are going to CCU!) 

• Do not offer sodium nitroprusside to people with acute heart failure 

• Do not routinely offer inotropes or vasopressors to people with acute heart failure. 

You can, however, consider them under the following circumstances – Consider inotropes or vasopressors in people with acute heart failure with potentially reversible cardiogenic shock. Administer these treatments in a cardiac care unit or high dependency unit or an alternative setting where at least level 2 care can be provided. SO essentially if you have a peri arrest patient with a low BP/CO you should use them but otherwise avoid as they do risk causing arrythmias, myocardial ischaemia and have been shown to increase mortality. 

So, in summary: always use diuretics – and avoid everything else routinely unless under very specific circumstances – nitrates – only if signs of cardiac ischaemia, vasopressors/inotropes only if reversible cardiogenic shock… 

Non-pharmacological management 

• Do not routinely use noninvasive ventilation (continuous positive airways pressure [CPAP] or noninvasive positive pressure ventilation [NIPPV]) in people with acute heart failure and cardiogenic pulmonary oedema.

• However, if a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting noninvasive ventilation without delay:
• at acute presentation or
• as an adjunct to medical therapy if the person’s condition has failed to respond.

Consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:

• respiratory failure or
• reduced consciousness or physical exhaustion.

SO essentially try drugs first (loop diuretics) unless they are tiring or have respiratory failure… this is all still based on C3PO which showed no difference in mortality or need for intubation no matter the mode of oxygen delivery.  Although it did show a trend to improved symptoms of breathlessness and therefore, we assume happier patients when using CPAP.

SO how do we summarise these guidelines (a lot of words and a lot of pages really to tell you to do very little), so I’m going to steal the words of Valentino our fabulous Cardiac ACP who I have mentioned before 

‘Acute treatment is 

1. diuretic 
2. Nitrates only if cardiac ischaemia
3. CPAP only if respiratory failure’

1. Acute Rhabdomyolysis – RCEMLearning
2. Rhabdomyolysis CCC
3. emDocs Cases: Evidence-Based Recommendations for Rhabdomyolysis -emDOCs.net – Emergency Medicine Education

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