Acute heart failure (acute pulmonary oedema)

Last updated: April 2021

Clinical features

– Sudden onset or exacerbation of dyspnoea
– Fatigue, increased time to recover after exercise
– Bilateral peripheral oedema
– Cold extremities
– Elevated jugular venous pressure
– On auscultation: bilateral pulmonary crepitations and/or extra heart sound (gallop rhythm)

Signs of severity:
– Severe respiratory distress (intercostal retractions, nasal flaring, see-saw breathing, SpO2 < 90%, etc.), cyanosis, profuse sweating, confusion
– Systolic blood pressure < 90 mmHg (cardiogenic shock) 
– Rapid and excessive increase in arterial blood pressure (hypertensive emergency)
– Heart rate (HR) > 130/minute or < 40/minute
– Respiratory rate (RR) > 30/minute or < 12/minute 
– Chest pain if underlying cardiac ischemia

Paraclinical investigations

Diagnosis is mainly clinical.
− ECG: look for signs of myocardial ischemia or arrhythmia.
If available:
− Chest x-ray: signs vary depending on the severity of pulmonary oedema. In early stage, dilation of vessels in upper lobes then perihilar haze and thickening of septa. In advanced stage, prominent opacities in hilar and perihilar regions and pleural effusion. Can exclude other lung disease, such as pulmonary infection.
- POCUS1 :
• Perform 12-zone lung exam to evaluate for signs of bilateral pulmonary oedema and/or pleural effusions.
• Perform 5-view cardiac exam to evaluate for signs of acute volume overload and/or decreased cardiac function.
– Monitoring: full blood count, electrolytes, serum creatinine; cardiac troponins if available.


Systolic blood pressure is < 90 mmHg 

See Shock, Chapter 1.

Systolic blood pressure is ≥ 90 mmHg1,2

– The patient must be hospitalised.
– Place patient in semi-seated position, legs down.
– In patients with SpO2 < 90%, administer oxygen with a mask at the necessary flow rate to maintain SpO2 ≥ 95%. If pulse oximetry is not available, administer oxygen at a flow rate of 6 to 10 litres/minute to patients with signs of hypoxia.
– Insert an IV line.
– If there are signs of volume overload (and/or in case of hypertensive emergency): furosemide IV, 40 to 80 mg, may be repeated if necessary according to urine output, signs of respiratory distress and SpO2. If the patient was already taking furosemide at doses of > 40 mg, administer pre-existing dose by IV route.
– Add a short-acting nitrate (vasodilator) if systolic blood pressure is > 100 mmHg. The aim is to gradually lower systolic blood pressure to near-baseline value. If the patient’s baseline value is unknown, for information, lower systolic blood pressure to 120-150 mmHg and the diastolic pressure to under 110 mmHg.
isosorbide dinitrate sublingual (5 mg tablet)
5 mg per dose; if necessary up to 2 doses taken 10 minutes apart
isosorbide dinitrate IV (10 ml ampoule, 1 mg/ml)
2 mg (= 2 ml) by slow IV injection (over 2 minutes) then if necessary 2 to 10 mg/hour by continuous infusion with an electric syringe pump
glyceryl trinitrate sublingual (0.5 mg tablet)
0.5 mg per dose; if necessary up to 3 doses taken 5 minutes apart, on condition that systolic blood pressure is > 120 mmHg
– Non-invasive ventilation using continuous positive airway pressure (CPAP) is recommended in patients with persistent hypoxaemia, unless contraindicated (e.g. impaired consciousness) and on condition that appropriate monitoring is available.
– Monitoring: HR, RR, BP, SpO2, mental status, urine output.

Subsequent treatment depends on the underlying pathology (chronic heart failurehypertension, acute coronary syndrome, etc.).

Ref Notes
1 POCUS should only be performed and interpreted by trained clinicians.


  1. Ponikowski P et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18(8):891-975. [Accessed 23 March 2021]

  2. Ezekowitz, Justin A. et al. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017;33:1342-1433. [Accessed 23 March 2021]