Acute Heart Failure

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Acute heart failure is extremely common amongst patients presenting to our ED’s. No doubt you’ll have several patients each day presenting who need assessment and treatment for this condition. Understanding some of the underlying physiology and evidence base surrounding the condition can greatly improve the treatment you can give to your patients.

In this podcast we’ll run through just that. Below are a list of some of the references and resources we’ll cover.

We’d love to hear any comments or feedback you have for us.

Rob Fenwick

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Relevant FOAMed resources

St Emlyns (blog post)

EMCRIT (podcast)


National Institute for Health and Care Excellence. (2014) Acute heart failure: diagnosing and managing acute heart failure in adults. (Clinical Guideline CG187).Available from:

European Society of Cardiology; Nieminem, M. S., Bohm, M., Cowie, M. R., Drexler, H., Filippatos, G. S., Jondeau, G., Hasin, Y., Lopez-Sendon, J., Mebazaa, A., Metra, M., Rhodes, A & Swedberg, K. (2005) Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: The task force on acute heart failure of the European Society of Cardiology. European Heart Journal. Vol 26, pp384-416.

Cochrane systematic reviews; Salvador, D. K., Punzalan, F. E & Ramos, G. C. (2005) Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database of Systematic Reviews. Issue 3. Article number: CD003178.

Wakai, A., McCabe, A., Kidney, R., Brooks, S. C., Seupaul, R. A., Diercks, D. B., Salter, N., Fermann, G. J & Pospisil, C. (2012) Nitrates for acute heart failure syndromes. Cochrane Database of Systematic Reviews. Issue 8. Article number: CD005151.

Vital, F. M. R., Ladeira, M. T & Atallah, A. N. (2013) Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic oedema. Cochrane Database of Systematic Reviews. Issue 5. Article Number CD005351.

Referenced articles


Hasselblad, V., Gattis-Stough, W., Shah, M. R., Lokhnygina, Y., O’Connor, C. M., Califf, R. M & Adams, K. F. (2007) Relationship between dose of loop diuretics and outcomes in a heart failure population: Results of the ESCAPE trial. European Journal of Heart Failure. Vol 9, number 10, pp1064-1069.

Faris, R., Flather M., Purcell, H., Henein, M., Poole-Wilson, P & Coats, A. (2002) Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials. International Journal of Cardiology. Vol 82, number 2, pp149-158.


Publication committee for the VMAC (Vasodilation in the Management of Acute CHF) investigators. (2002) Intravenous nesiritide vs. nitroglycerin for treatment of decompensated congestive heart failure: a randomised controlled trial. JAMA. Vol 287, number 12, pp1531-1540.

Sharon, A., Shpirer, I., Kaluski, E., Moshkovitz, Y., Milovanov, O., Polak, R., Blatt, A., Simovitz, A., Shaham, O., Faigenberg, Z., Metzger, M., Stav, D., Yogev, R., Golik, A., Krakover, R., Vered, Z & Cotter, G. (2000) High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. Journal of the American College of Cardiology. Vol 36, pp832-837.

Cotter, G., Metzkor, E., Kaluski, E., Faigenberg, Z., Miller, R., Simovitz, A., Shaham, O., Marghitay, D., Koren, M., Blatt, A., Moshkovitz, R., Zaidenstein, R & Golik, A. (1998) Randomised trial of high-dose isosorbide dinitrate plus low-dose furosemide versus furosemide plus low-dose isosorbide dinitrate in severe pulmonary oedema. The Lancet. Vol 351, pp389-393.

Levy, P., Compton, S., Welch, R., Delgado, G., Jennett, A., Penugonda, N., Dunne, R & Zalenski, R. (2007) Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Annals of Emergency Medicine. Vol 50, number 2, pp144-152.


Vital, F. M. R., Ladeira, M. T & Atallah, A. N. (2013) Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic oedema. Cochrane Database of Systematic Reviews. Issue 5. Article Number CD005351.

Gray, A., Goodacre, S., Newby, D. E., Masson, M., Sampson, F & Nicholl, J., for the 3CPO Trialists. (2008) Noninvasive ventilation in acute pulmonary edema. New England Journal of Medicine. Vol 359, pp142-151.

Plaisance, P., Pirracchio, R., Berton, C., Vicaut, E & Payen, D. (2007) A randomised study of out-of-hospital continuous positive airway pressure for acute cardiogenic pulmonary oedema: physiological and clinical effects. European Heart Journal. Vol 28, pp2895-2901.


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7 thoughts on “Acute Heart Failure

  1. simon says:


    great article as always. for some reason though i can never get the podcast to play. any ideas why? i use firefox.

  2. sl says:


    Afraid not ideas other than browsers or blocked pop-ups?

    Try through the iTunes feed otherwise

    Hope you get it sorted!


  3. Steve McGuire says:

    Great podcast, well done.

    As for failed podcast of poster above…had to go to 3rd browser for playing podcast. chrome -> safari -> firefox worked. On Mac.

    still worth it. but may want to have your giant IT department take a look.


  4. sl says:

    Hi Steve,

    We’ve changed the mp3 plug in on the site. Let me know if this solves the problem?



  5. ... says:

    With regards to diuretic doses – the paper cited (Hasselblad et al) merely states that higher doses of furosemide are associated with increased mortality. There is no causative link established. Indeed, the paper itself states “… higher diuretic use could have been a marker of a sicker patient at high risk of mortality regardless of diuretic therapy.”

    “Prospective, carefully controlled studies will be required to clarify whether there is a causal relationship between diuretic use and adverse outcomes, or alternatively if diuretic dosage is just a surrogate for disease severity.”

    The DOSE study which suggested that infusions and boluses of diuretics have similar efficacy was looking at symptom relief as an endpoint rather than mortality. It suggested that higher doses of diuretics (2.5x the patient’s previous oral dose, but given intravenously as a high dose, or 1x the oral dose given intravenously as a low dose) have more efficacy in symptom control at the expense of an increase in renal impairment.

    Concluding in favour of high dose nitrates with conservative use of diuretics based on the results of two studies of 110 and 40 people seems a little strange as it is going against the vast majority of evidence and accepted practice, especially when one paper looks at 24 hour outcomes!

  6. sl says:

    Hello unnamed

    Thanks for the reply, always great to get some feedback/comments

    I agree with a lot of your points and it’s important to emphasise that we’re talking about those sick patients with pulmonary oedema who are critically unwell. Our main points were;

    – Nitrates – safe, good physiological rationale and work immediately.

    – Furosemide- it’s what these patients get and that’s probably OK but it’s not the magic drug some may think it is. There is not a strong evidence base to confirm a strong mortality benefit in this specific critically unwell cohort. It is important to understand the renal side effects that can occur and whilst symptom control is important longer term hard outcomes are probably more important.

    So again thanks for the comments, we’re not trying to say the answer is black and white, actually far from it but the evidence doesn’t give the magic bullet yet.


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