Acute Heart Failure — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Bedside phenotype
   Which phenotype — perfusion (warm/cold) × congestion (wet/dry)? (Initial: oxygen (SpO2 <90% or respiratory distress → oxygen / NIV), monitoring, find the trigger CHAMPIT (ACS, hypertensive emergency, arrhythmia, mechanical complication, PE, infection, tamponade). Congestion (wet) = pulmonary/systemic congestion; hypoperfusion (cold) = cool extremities, mottling, oliguria, altered mentation, narrow pulse pressure.)
   • Warm-wet (good perfusion + congestion) → Warm-wet
   • Cold-wet (hypoperfusion + congestion) → Cold-wet
   • Warm-dry / cold-dry (no clear congestion) → Warm-dry / cold-dry
2. [End] Warm-wet
   Warm-wet (most common, >80%): decongestion is the priority — IV loop diuretic (furosemide; if already on oral, switch to IV at a dose ≥ the usual oral-equivalent); add a vasodilator (nitroglycerin, etc.) if BP is adequate to lower pre- and afterload. Monitor urine output, electrolytes and renal function; start/optimize GDMT (including an SGLT2i).
3. [End] Cold-wet
   Cold-wet (worst prognosis): hypoperfusion first — with low BP/shock use an inotrope (dobutamine/levosimendan), and a vasopressor (norepinephrine) if needed to restore perfusion before cautious diuresis; consider mechanical circulatory support if refractory. Always find and correct the trigger (especially ACS).
4. [End] Warm-dry / cold-dry
   Warm-dry (compensated): no acute congestion — optimize oral GDMT, look for the cause of decompensation, arrange follow-up. Cold-dry (poor perfusion without congestion): a cautious fluid challenge ± inotrope to improve cardiac output, with close monitoring.

Source guidelines & references

• 2021 ESC Guidelines for diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599 + 2023 focused update · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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