Acute heart failure: symptoms, emergency care and treatment in the UK

Heart failure is a condition in which the heart cannot pump blood properly. The NHS stresses that it does not mean the heart has stopped or is about to stop. Acute heart failure refers to a sudden onset or a rapid worsening of symptoms, which is why people often need urgent hospital care.

The NHS says heart failure can happen suddenly, such as after a heart attack or infection, or develop from long-term strain on the heart from high blood pressure or coronary heart disease. The British Heart Foundation says it can happen suddenly or progress slowly over months or years.

NICE guideline CG187 covers diagnosing and managing acute heart failure in adults, and recommends that discharge and ongoing care are planned in line with its guideline on chronic heart failure.

The NHS lists symptoms of heart failure as feeling out of breath doing everyday activities or lying down, being more out of breath than expected, feeling weak, light-headed or very tired, swelling in the feet, ankles, legs or tummy or feeling bloated, sudden weight gain, coughing at night and coughing up frothy pink phlegm. The British Heart Foundation adds fainting or feeling lightheaded and shortness of breath at rest.

In an acute episode these symptoms come on quickly or worsen over days. Fluid backing up into the lungs is what produces severe breathlessness and the frothy pink phlegm.

The NHS says to ask for an urgent GP appointment or get help from NHS 111 if you feel breathless when lying down or from everyday activity, you are coughing up frothy pink phlegm, or you have suddenly gained weight.

Call 999 if you are having severe difficulty breathing, such as gasping, choking or not able to get words out, if your lips or skin are pale, blue or grey, or if someone has passed out and is not responding normally. The NHS advises not to drive yourself to A&E. The British Heart Foundation adds to call 999 for possible heart attack symptoms or chest pain.

The NHS lists possible causes including heart valve disease, cardiomyopathy, heart rhythm problems, chronic kidney disease, anaemia, haemochromatosis and thyroid problems, alongside heart attack, infection, high blood pressure and coronary heart disease. You may be more at risk if you are 65 or older, living with overweight or obesity, pregnant, smoke, drink a lot of alcohol or use cocaine.

The British Heart Foundation lists the most common causes as a heart attack, cardiomyopathy and high blood pressure, with others including arrhythmias, amyloidosis, anaemia, congenital heart conditions, valve disease, pulmonary hypertension, some cancer treatments, thyroid disease and drinking more than 14 units a week.

NICE recommends taking a history, performing a clinical examination and undertaking standard investigations such as an ECG, chest X-ray and blood tests. In people with new suspected acute heart failure, a single measurement of natriuretic peptides is used to rule out the diagnosis, with BNP below 100 ng/litre or NT-proBNP below 300 ng/litre ruling it out.

If natriuretic peptide levels are raised, NICE says transthoracic Doppler 2D echocardiography should be performed to establish the presence or absence of cardiac abnormalities, and to consider performing it within 48 hours of admission to guide early specialist management.

NICE recommends offering intravenous diuretic therapy to people with acute heart failure, with close monitoring of kidney function, weight and urine output. It says not to routinely offer opiates, nitrates, inotropes or vasopressors, with exceptions for specific circumstances such as reversible cardiogenic shock.

On breathing support, NICE says not to routinely use non-invasive ventilation, but to consider it without delay for cardiogenic pulmonary oedema with severe breathlessness and acidaemia, and to consider invasive ventilation if heart failure leads to respiratory failure, reduced consciousness or exhaustion. After stabilisation, people already taking beta-blockers should usually continue them, and those with reduced ejection fraction should be offered an ACE inhibitor (or ARB) and an aldosterone antagonist during admission.

NICE says a follow-up clinical assessment should be undertaken by a member of the specialist heart failure team within 2 weeks of discharge. The NHS says there is currently no cure for heart failure, but treatment aims to ease symptoms and prevent the condition worsening, using medicines such as diuretics, ACE inhibitors or ARBs and beta blockers, surgery or devices where needed, and cardiac rehabilitation, which everyone diagnosed should be offered.

The British Heart Foundation acknowledges that living with uncertainty is hard, and that learning about the condition and being involved in decisions can help you feel more in control.

Acute heart failure is an emergency and is managed through 999 and NHS emergency departments, with admission to cardiology or medical wards and heart failure specialist input, as NICE recommends. Long-term care is usually delivered by community heart failure teams and GP surgeries.

Private cardiology reviews can help with echocardiography or medication optimisation once stable, but sudden worsening should always be treated as an emergency using 999 or A&E.