Acute Heart Failure & Cardiogenic Shock

General framework — adapt local protocol · Last reviewed: Jul 2026

Initial Action

Assess ABC, vitals, SpO₂, ECG. Look for precipitants (ischaemia, arrhythmia, infection, non-adherence, etc.).

Decision

Classify haemodynamic profile (Stevenson-Nohria) — congestion (wet/dry) and perfusion (warm/cold)?

Warm & Wet

Congested, adequate perfusion — the most common

Cold & Wet

Congestion + hypoperfusion — suspect cardiogenic shock

Warm & Dry

Well compensated — optimise oral therapy

Cold & Dry

Rare — beware relative hypovolaemia

IV loop diuretic (e.g. furosemide) as first-line decongestion.

For hypertension / severe congestion with adequate BP: add IV vasodilator (e.g. nitrate) to relieve dyspnoea.

Evaluate diuretic response at 1–2 h; titrate dose if response is inadequate.

Consider inotrope (dobutamine/milrinone) ± vasopressor (norepinephrine) for hypotension.

Cautious diuresis, only after perfusion improves. Consider ICU / mechanical circulatory support referral.

Severe respiratory distress / pulmonary oedema → consider non-invasive ventilation (CPAP/BiPAP). Target SpO₂ 94–98%.

Dose, dilution, and infusion rate for the drugs above (furosemide, dobutamine, norepinephrine) are in Drug & Fluid → Vasopressor/Inotrope.

General framework — specific dosing and drug choice may vary by local hospital policy. Not a substitute for clinical judgement.