Decompensated heart failure — structured written assessment

This scenario is fictional and invented for teaching; it does not describe a real person.

SAQ 1 (10 marks)

A 76-year-old woman with known HF arrives with two days of increasing breathlessness and orthopnoea. She takes oral furosemide 40 mg daily. Respiratory rate is 30 breaths/min, SpO₂ 87% on air, BP 164/92 mmHg, JVP raised, crackles to the mid-zones, oedema to the knees. Lactate is 1.4 mmol/L.^[1]

1. Name the four 2026 ESC clinical categories of decompensated HF and state which signs you would use to judge congestion and hypoperfusion. (3) ^[1]
2. Write her oxygen and ventilation plan with the ESC 2026 thresholds and classes. (3) ^{[1] [11]}
3. Write her initial diuretic prescription and how you will judge the response in the first 6 hours. (4) ^{[1] [5]}

Model answers

1. Decompensated left-sided HF, decompensated right-sided HF, acute pulmonary oedema and cardiogenic shock (1 mark). Left-sided congestion: dyspnoea, orthopnoea, cough, tachypnoea, rales, S3, pleural effusion, raised natriuretic peptides. Right-sided congestion: peripheral oedema, abdominal distension, hepatomegaly, jugular vein distension, hepatojugular reflux, pleural effusion, elevated serum creatinine, elevated bilirubin, ALP and GGT, slightly elevated natriuretic peptides (1 mark). Hypoperfusion: cold, sweaty extremities, pale skin, dizziness, mental confusion, oliguria, narrow pulse pressure, elevated serum lactate, elevated serum creatinine, elevated aminotransferase (1 mark).^[1]
2. Oxygen because SpO₂ is below 90% (Class I, Level C); indiscriminate oxygen in non-hypoxaemic patients may be harmful (1 mark). She has respiratory distress (respiratory rate above 25 breaths/min, SpO₂ below 90%), so NIPPV should be considered and started as soon as possible (Class IIa, Level B2) (1 mark).^[1] Cochrane (adults with acute cardiogenic pulmonary oedema, NPPV versus standard medical care): NPPV probably reduces intubation (RR 0.49) and may reduce hospital mortality (RR 0.65). Intubation is recommended for persistent and progressive respiratory failure despite oxygen administration or non-invasive ventilation (Class I, Level C) (1 mark).^{[11] [1]}
3. She has fluid overload (oedema to the knees), so an i.v. loop diuretic is recommended (Class I, Level A). She is already on furosemide, so an i.v. dose of twice her usual oral dose (80 mg i.v.) should be considered (1 mark). DOSE (patients on 80–240 mg/day oral furosemide) found no significant difference between bolus and infusion, or in global symptoms between 2.5 times and 1 times the oral dose; its authors note the findings may not apply to patients with more modest diuretic requirements, such as hers (1 mark).^{[1] [5]} Check urinary sodium at 2 h (satisfactory ≥70 mEq/L) and urine output over the first 6 h (satisfactory ≥100 mL/h) (1 mark). If insufficient, the i.v. dose can be doubled and/or a non-loop diuretic added (1 mark).^[1]

SAQ 2 (10 marks)

The same patient responds poorly. At 24 hours urine output totals 2.1 L, she remains congested, and creatinine has risen slightly. By day 4 she is euvolaemic, BP 122/74 mmHg, potassium 4.3 mmol/L. LVEF is 35%; she takes ramipril and bisoprolol at low doses.^[1]

1. What does the 2026 ESC guideline advise at 24 hours, and how do you interpret the creatinine rise? (3) ^[1]
2. Give the non-loop diuretic options with doses and the trial evidence for each. (3) ^{[1] [6] [7]}
3. Outline your pre-discharge and early follow-up plan with ESC 2026 classes and the supporting trial. (4) ^{[1] [10] [22]}

Model answers

1. Diuresis below 3 L at 24 h with persisting congestion means further escalation should be considered on day 2 (1 mark). Small, transient creatinine rises are not linked to poor outcome if decongestion is achieved (1 mark). Adverse outcomes are seen with worsening kidney function plus a poor diuretic response (1 mark).^[1] AHA/ACC/HFSA 2022: diuresis should not be stopped prematurely for small creatinine changes.^[2]
2. As she still has fluid overload and was previously treated with loop diuretics, adding short-term i.v. acetazolamide or oral hydrochlorothiazide should be considered to reduce congestion (Class IIa, Level B1). Acetazolamide 500 mg i.v. once daily; hydrochlorothiazide 25 mg daily if eGFR is above 50, 50 mg if 20–50, 100 mg if below 20 mL/min/1.73 m² (1 mark).^[1] ADVOR: successful decongestion within 3 days 42.2% versus 30.5%, with no significant difference in death or HF rehospitalisation during 3 months of follow-up (1 mark).^[6] CLOROTIC: more weight loss at 72 h (2.3 versus 1.5 kg) but no dyspnoea benefit and more impaired renal function (1 mark).^[7]
3. Start an SGLT2 inhibitor in hospital after stabilisation (Class I, Level B1); EMPULSE used empagliflozin 10 mg once daily (1 mark).^{[1] [10]} Carefully evaluate for persistent congestion before discharge (Class I, Level C), using clinical signs, natriuretic peptides, kidney function and electrolytes, and imaging (1 mark). Rapidly start and up-titrate FMT before discharge and at frequent visits in the first 6 weeks (Class I, Level B2), with safety indicators, including BP, heart rate, creatinine, potassium and NT-proBNP, helping to guide uptitration (1 mark).^[1] STRONG-HF: 180-day HF readmission or death 15.2% versus 23.3% (risk ratio 0.66) (1 mark).^[22]