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Acute heart failure and pulmonary oedema
In acute heart failure the patient is classified as "wet or dry" and "warm or cold", the precipitant is sought, and treatment follows — a diuretic for wet, a vasodilator for high blood pressure and an inotrope for cold.
Why it matters in the exam
This is a classic emergency-room scenario: a breathless patient with crackles, low saturation and either high or low blood pressure. The question tests the order of actions (sit the patient up, oxygen only for hypoxaemia, non-invasive ventilation, intravenous furosemide, nitrates), the difference between hypertensive pulmonary oedema and cardiogenic shock, and the need to look for a precipitant: an acute coronary syndrome, an arrhythmia, hypertension, infection, pulmonary embolism, non-adherence or a mechanical problem. Candidates are also asked how BNP and lung ultrasound help the differential diagnosis, and when nitrates are forbidden.
The exam also likes to test what is not done: oxygen is not given to everyone, morphine is not routine, and blood pressure is not lowered in a patient in shock. Candidates are asked what to do when the diuretic does not work: check urine sodium and urine output in the first hours, increase the dose and add a diuretic from another class.
Key points
- Classify: wet or dry, warm or cold.
- Warm and wet: IV furosemide, and nitrates when systolic pressure is above 110.
- Cold and wet: cardiogenic shock — inotrope, vasopressor and treatment of the cause (usually coronary).
- Always look for a precipitant: ischaemia, arrhythmia, hypertension, infection, embolism, non-adherence.
- BNP below 100 or NT-proBNP below 300 pg/mL makes acute heart failure unlikely.
Summary table
| Profile | Findings | Main treatment | What not to do |
|---|---|---|---|
| Warm and wet (most common) | Congestion, crackles, oedema, normal or high blood pressure | IV furosemide; nitrates if systolic pressure is above 110 | Do not wait for an X-ray before a diuretic in a clear case |
| Hypertensive pulmonary oedema | Rapid onset, very high blood pressure, lung congestion with little peripheral oedema | High-dose nitrates, non-invasive ventilation, diuretic | Do not give fluids |
| Cold and wet (cardiogenic shock) | Systolic pressure below 90, cold limbs, oliguria, raised lactate | Inotrope (dobutamine), vasopressor, urgent angiography if coronary cause | No nitrates and no beta-blocker |
| Cold and dry | Hypoperfusion without congestion | Careful fluid challenge, haemodynamic assessment | No diuretic |
| Diagnosis | BNP below 100 or NT-proBNP below 300 pg/mL makes acute heart failure unlikely | Echocardiogram, ECG, troponin, lung ultrasound (B-lines) | Do not blame the heart without looking for infection or embolism |
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Sources
- ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2021, with the 2023 focused update — Acute heart failure
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Acute Heart Failure and Cardiogenic Shock
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.