EM · Acute decompensated heart failure
Acute decompensated heart failure and cardiogenic pulmonary oedema
Also known as Acute pulmonary oedema · Cardiogenic pulmonary oedema · Acute heart failure · Flash pulmonary oedema
Acute decompensated heart failure and cardiogenic pulmonary oedema in the emergency department — the wet/dry × warm/cold bedside profiles (Nohria), natriuretic-peptide rule-out (Breathing Not Properly, PRIDE), oxygen and early NIV (ESC 2021, 3CPO, Cochrane), the IV loop diuretic with early response checks (DOSE, HFA, ADVOR), vasodilators when SBP is over 110 mmHg (Cotter), cardiogenic shock (SOAP II, OptimaCC, SCAI stages, CULPRIT-SHOCK, MCS trials), what not to do (morphine, ultrafiltration, renal-dose dopamine) and discharge (orthodema, STRONG-HF). ACEM-primary, globally tagged.
Checked against its sources on 8 Oct 2026
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Red flags
- Respiratory distress (RR over 25, SpO2 under 90%) needs non-invasive positive pressure ventilation as soon as possible; intubate for progressive respiratory failure despite it
- IV vasodilators only when SBP is over 110 mmHg — the hypoperfused, hypotensive patient is in cardiogenic shock
- Morphine is not routine — in ADHERE it was an independent predictor of mortality
- Find the precipitant — in OPTIMIZE-HF the commonest identified were pneumonia/respiratory process, ischaemia and arrhythmia
- A normal chest X-ray does not exclude congestion — 20% of congested patients have one
Meet the patient
A 72-year-old man with known HFrEF sits bolt upright at 3am, saturations 84 per cent on room air, respiratory rate 34, BP 198/108 in fast atrial fibrillation, warm peripheries, raised JVP, crackles to the mid-zones. He missed his furosemide for three days. Respiratory rate over 25 and SpO2 under 90 per cent: NIV goes on now, and with an SBP well over 110 mmHg a vasodilator is an option.[1]
One decision gates every acute heart failure presentation: warm or cold? Read the profile at the bedside, treat to it, and find the precipitant in parallel.[7]
References30ShowHide
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- [2]Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. The New England journal of medicine, 2008.PMID 18614781
- [3]Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure. The New England journal of medicine, 2011.PMID 21366472
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- [9]Teerlink JR, Cotter G, Davison BA, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial. Lancet (London, England), 2013.PMID 23141816
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