Acute heart failure – NICE guideline

NICE AHFThe new NICE acute heart failure guideline for acute heart failure in adults is out. Leaves quite a lot of room for interpretation; few hard and fast recommendations. Sizeable section on further research.





In a nutshell:

Have a heart failure team

  • Cardiology ward and outreach


  • Rule out heart failure if BNP <100 or NT-proBNP <300.
  • Echo those with elevated BNP.


No routine opiates and don’t use PA catheters.

1. Stop the beta blocker if shocked, bradycardic on in 3rd degree block

2. Diuresis:

  • start or augment
  • consider ultrafiltration if diuretic resistant.

3. Nitrates:

  • not routinely
  • give for concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease. NOT nitroprusside.

4. Inotropes

  • not routinely
  • use if the cause is reversible – not clear what this means.

5. NIV:

  • straight away for cardiogenic pulmonary oedema with  dyspnoea AND acidosis.
  • consider if respiratory failure not settling, or patient is tiring.

6. Specialist centre involvement

  • Discuss early if reversible severe acute heart failure or potential heart transplant recipient.
  • Get their valve sorted if that’s the problem!

Once stable

  1. Beta blocker – watch rate
  2. ACE – watch renal function
  3. Aldosterone antagonist

Research recommended

1. Fluid removal

  • Dopamine
  • Thiazides
  • Ultrfiltration

2. Balloon pumps




St.Emlyns blog and their recommended reading