The presentation of AHF can vary but tends to fall in to the following 4 categories, which can be determined clinically and can help guide your approach to treatment; warm-dry, warm-wet, cold-dry, cold-wet.
It is worth noting that the vast majority of patients will be norm-hypertensive. However, 5-8% are Hypertensive this confers a very poor prognosis.
ECG: Rarely normal (High NPV), and may identify underlying cause
CXR: Pulmonary congestion, Effusion, Cardiomegaly (20% will have an almost “Normal” CXR)
BNP: Can be helpful (we have it)
>845 show increased mortality
<100 AHF is unlikely
BNP is not a specific test and will elevate for many reasons
POCUS: This can be very useful in identifying cases but training is required [Bilat B lines in 2 zones each side]
Condition specific tests: Try to identify the underlying trigger dependent on history and exam (e.g. ABG, Trop, U&E, TFT, LFT, CTPA)
ECHO: this is important but not necessary in the ED phase (unless the patient has haemodynamic instability i.e. cardiogenic shock)
Treatment – Time Matters!!!
Mortality increased by 1%/hour IV treatment not started
Treatment after 12hrs from onset makes little difference
Treat The Cause!: If you can identify the trigger treat it it will in turn improve the AHF. (e.g. AMI, Arrythmia(Tachy/Brady), Massive PE)
Vasodilator: has 2 effects reducing vascular resistance and thus increasing stroke volume [NOT to be used if sBP<90mmHg]