1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendation). See about this guideline for details.

1.1 Organisation of care

1.1.1 All hospitals admitting people with suspected acute heart failure should provide a specialist heart failure team that is based on a cardiology ward and provides outreach services.

1.1.2 Ensure that all people being admitted to hospital with suspected acute heart failure have early and continuing input from a dedicated specialist heart failure team.

1.1.3 Plan the following with people with acute heart failure in line with chronic heart failure (NICE guideline CG108):

  • discharge from hospital after the acute phase and

  • subsequent management in primary care, including ongoing monitoring and care provided by the multidisciplinary team and

  • information and communication about their condition, its treatment and prognosis.

1.1.4 A follow‑up clinical assessment should be undertaken by a member of the specialist heart failure team within 2 weeks of the person being discharged from hospital.

1.2 Diagnosis, assessment and monitoring

1.2.1 Take a history, perform a clinical examination and undertake standard investigations – for example, electrocardiography, chest X‑ray and blood tests – in line with chronic heart failure (NICE guideline CG108).

1.2.2 In people presenting with new suspected acute heart failure, use a single measurement of serum natriuretic peptides (B‑type natriuretic peptide [BNP] or N‑terminal pro‑B‑type natriuretic peptide [NT‑proBNP]) and the following thresholds to rule out the diagnosis of heart failure:

  • BNP less than 100 ng/litre

  • NT‑proBNP less than 300 ng/litre.

1.2.3 In people presenting with new suspected acute heart failure with raised natriuretic peptide levels (see recommendation 1.2.2), perform transthoracic Doppler 2D echocardiography to establish the presence or absence of cardiac abnormalities.

1.2.4 In people presenting with new suspected acute heart failure, consider performing transthoracic Doppler 2D echocardiography within 48 hours of admission to guide early specialist management.

1.2.5 Do not routinely offer pulmonary artery catheterisation to people with acute heart failure.

1.3 Initial pharmacological treatment

1.3.1 For guidance on patient consent and capacity follow recommendations 1.2.12 and 1.2.13 in patient experience in adult NHS services (NICE guideline CG138).

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

1.3.3 Offer intravenous diuretic therapy to people with acute heart failure. Start treatment using either a bolus or infusion strategy.

1.3.4 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.

1.3.5 Closely monitor the person's renal function, weight and urine output during diuretic therapy.

1.3.6 Discuss with the person the best strategies of coping with an increased urine output.

1.3.7 Do not routinely offer nitrates to people with acute heart failure.

1.3.8 If intravenous nitrates are used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, monitor blood pressure closely in a setting where at least level 2 care[1] can be provided.

1.3.9 Do not offer sodium nitroprusside to people with acute heart failure.

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

1.3.11 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[1] can be provided.

1.4 Initial non‑pharmacological treatment

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

1.4.2 If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non‑invasive ventilation without delay:

  • at acute presentation or

  • as an adjunct to medical therapy if the person's condition has failed to respond.

1.4.3 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.

1.4.4 Do not routinely offer ultrafiltration to people with acute heart failure.

1.4.5 Consider ultrafiltration for people with confirmed diuretic resistance[2].

1.5 Treatment after stabilisation

1.5.1 In a person presenting with acute heart failure who is already taking beta‑blockers, continue the beta‑blocker treatment unless they have a heart rate less than 50 beats per minute, second or third degree atrioventricular block, or shock.

1.5.2 Start or restart beta‑blocker treatment during hospital admission in people with acute heart failure due to left ventricular systolic dysfunction, once their condition has been stabilised – for example, when intravenous diuretics are no longer needed.

1.5.3 Ensure that the person's condition is stable for typically 48 hours after starting or restarting beta‑blockers and before discharging from hospital.

1.5.4 Offer an angiotensin‑converting enzyme inhibitor (or angiotensin receptor blocker if there are intolerable side effects) and an aldosterone antagonist during hospital admission to people with acute heart failure and reduced left ventricular ejection fraction. If the angiotensin‑converting enzyme inhibitor (or angiotensin receptor blocker) is not tolerated an aldosterone antagonist should still be offered[3].

1.5.5 Closely monitor the person's renal function, electrolytes, heart rate, blood pressure and overall clinical status during treatment with beta‑blockers, aldosterone antagonists or angiotensin‑converting enzyme inhibitors.

1.6 Valvular surgery and percutaneous intervention

1.6.1 Offer surgical aortic valve replacement to people[4] with heart failure due to severe aortic stenosis assessed as suitable for surgery.

1.6.2 Consider transcatheter aortic valve implantation (TAVI) in selected people[4], with heart failure caused by severe aortic stenosis, who are assessed as unsuitable for surgical aortic valve replacement. Details of all people undergoing TAVI should be entered into the UK Central Cardiac Audit database.

1.6.3 For guidance on coronary revascularisation see chronic heart failure (NICE guideline CG108).

1.6.4 Consider surgical mitral valve repair or replacement for people with heart failure due to severe mitral regurgitation assessed as suitable for surgery.

1.7 Mechanical assist devices

1.7.1 At an early stage, the specialist should have a discussion with a centre providing mechanical circulatory support about:

  • people with potentially reversible severe acute heart failure or

  • people who are potential candidates for transplantation.



[1] Level 2 care is for people needing more detailed observation or intervention, including support for a single failing organ system or postoperative care and for those stepping down from higher levels of care. From Levels of critical care for adult patients.

[2] Diuretic resistance is defined as dose escalation beyond a person's previously recognised dose ceiling or a dose approaching the maximum recommended daily dose without incremental improvement in diuresis. From Diuretics and ultrafiltration in acute decompensated heart failure.

[3] In February 2016, the Medicines and Healthcare products Regulatory Agency (MHRA) published advice on the concomitant use of spironolactone and renin-angiotensin system drugs in heart failure concerning the risk of potentially fatal hyperkalaemia. See the MHRA advice for more information.

[4] For information about patient selection, see transcatheter aortic valve implantation for aortic stenosis (NICE interventional procedure guidance 421).

  • National Institute for Health and Care Excellence (NICE)