A 70-year-old with known HFrEF (EF 25%) presents with acute breathlessness, frothy sputum, bilateral crackles to the apices, SpO2 86% on air. Talk us through your management.

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Accepted Answer

Acute pulmonary oedema — A-E. I'd sit the patient up, apply 15 L O2 via non-rebreathe targeting 94-98%, get IV access, 12-lead ECG, gas, troponin, BNP, U&E, CXR, and bedside echo. I'd give IV furosemide 80 mg, start GTN infusion titrated to BP, and call HDU early to prepare CPAP. While treating, I'd look for the precipitant — ACS, new AF with fast rate, infection, missed diuretic, NSAIDs. Once stabilised I'd review their disease-modifying therapy and ensure the four pillars of HFrEF therapy are optimised before discharge: ACEi/ARNI, beta-blocker, MRA and an SGLT2 inhibitor. I'd discuss escalation status with the patient given EF 25%, document a ceiling of care, and arrange community heart failure team follow-up.

Acute decompensated heart failure

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