Acute heart failure at the IMT (Internal Medicine Training) clinical station is answered with a rule-out threshold, one drug class and a list of things you will not give routinely. According to NICE CG187, a single BNP below 100 ng/L or NT-proBNP below 300 ng/L rules out new acute heart failure, intravenous diuretic is offered to everyone with the diagnosis, and opiates, nitrates, inotropes and non-invasive ventilation are not routine.

Key takeaways

  • NICE CG187 rules out new suspected acute heart failure with a single BNP below 100 ng/L or NT-proBNP below 300 ng/L; a raised level means transthoracic echocardiography, ideally within 48 hours of admission.
  • Offer intravenous diuretic therapy, as a bolus or an infusion, and consider a higher dose than the patient's usual one if they were already on a diuretic.
  • Do not routinely offer opiates, nitrates, inotropes or vasopressors, and do not offer sodium nitroprusside; nitrates are for specific situations such as ischaemia or severe hypertension with level 2 monitoring.
  • Non-invasive ventilation is not routine, but should be started without delay in cardiogenic pulmonary oedema with severe dyspnoea and acidaemia.
  • Continue an existing beta-blocker unless the heart rate is below 50, there is second or third degree block, or shock; start an ACE inhibitor and an aldosterone antagonist during the admission in reduced ejection fraction.
  • Every admission needs early input from the specialist heart failure team and a follow-up within 2 weeks of discharge.

How do you recognise acute heart failure in the scenario?

Acute heart failure is recognised as breathlessness with orthopnoea, a raised jugular venous pressure, bibasal crackles, peripheral oedema and a chest X-ray showing pulmonary oedema, in a patient with a cardiac history or a new precipitant. The station usually gives you a hypoxic, sweating patient at 3 a.m. who cannot lie flat.

Say the precipitant list early: acute coronary syndrome, arrhythmia, uncontrolled hypertension, infection, non-adherence to diuretics, and drugs such as NSAIDs. In practice, the diagnosis is rarely the challenge; the trigger is.

What does the A to E assessment and first hour look like?

The first hour of acute heart failure is an A to E assessment with the patient sat upright, oxygen titrated to target, intravenous access, an ECG, a chest X-ray and intravenous loop diuretic once the diagnosis is likely. NICE CG187 asks for history, examination and standard investigations in line with the chronic heart failure guideline.

  • Airway and breathing: sit up, oxygen to target, arterial blood gas for hypoxia and acidaemia, which decide the ventilation question
  • Circulation: blood pressure, rhythm on a monitor, a 12-lead ECG for ischaemia or arrhythmia, and intravenous furosemide as a bolus or infusion
  • Disability: conscious level and exhaustion, both of which change the decision about invasive ventilation
  • Exposure: oedema, temperature, weight, and a catheter for hourly urine output during diuresis
  • Bloods: natriuretic peptide if the diagnosis is new, troponin, renal function and electrolytes, and a chest X-ray

Which investigations confirm acute heart failure?

The investigations that confirm new acute heart failure are a single natriuretic peptide measurement followed by transthoracic Doppler echocardiography if it is raised. NICE CG187 says consider performing the echo within 48 hours of admission to guide early specialist management, and do not routinely offer pulmonary artery catheterisation.

Name the ECG, chest X-ray, troponin and renal profile as the standard set. Renal function, weight and urine output then need close monitoring throughout diuretic therapy.

What are the thresholds you must say?

The thresholds in acute heart failure are BNP below 100 ng/L or NT-proBNP below 300 ng/L to rule out the diagnosis in new presentations, echocardiography within 48 hours, a heart rate below 50 or second or third degree block or shock as the only reasons to stop a beta-blocker, and 48 hours of stability after starting or restarting a beta-blocker before discharge.

Say the units. NICE writes nanograms per litre, and a candidate who quotes picograms per millilitre for BNP is quoting a different reference range.

What is the definitive management of acute heart failure?

Definitive management of acute heart failure is intravenous loop diuretic, treatment of the precipitant, and the introduction of prognostic therapy before discharge. NICE CG187 is just as clear about what not to do routinely, and the panel scores both halves.

  • Offer intravenous diuretic as a bolus or infusion; consider a higher dose than the patient's usual one unless adherence before admission was the problem
  • Do not routinely offer opiates; do not routinely offer nitrates; do not offer sodium nitroprusside
  • If intravenous nitrates are used for concomitant ischaemia, severe hypertension or regurgitant valve disease, monitor blood pressure in a level 2 setting
  • Do not routinely offer inotropes or vasopressors; consider them only for potentially reversible cardiogenic shock in a cardiac care unit, HDU or equivalent
  • Non-invasive ventilation is not routine but should start without delay for cardiogenic pulmonary oedema with severe dyspnoea and acidaemia; consider invasive ventilation for respiratory failure, reduced consciousness or exhaustion
  • Ultrafiltration only for confirmed diuretic resistance

After stabilisation

After stabilisation, continue an existing beta-blocker unless heart rate is below 50, there is second or third degree block, or shock; start or restart one once intravenous diuretics are no longer needed and keep the patient stable for typically 48 hours before discharge. Offer an ACE inhibitor, or an ARB if not tolerated, and an aldosterone antagonist during the admission if the ejection fraction is reduced, with close monitoring of renal function, potassium, heart rate and blood pressure.

When and to whom do you escalate acute heart failure?

Escalate acute heart failure to the specialist heart failure team on admission, which NICE CG187 requires every hospital to provide, to critical care for anyone who needs non-invasive ventilation, inotropes or is heading for intubation, and to cardiology immediately if the precipitant is an acute coronary syndrome or an arrhythmia needing cardioversion. Mechanical circulatory support and transplant candidacy are discussed early by the specialist for potentially reversible severe disease.

How do you hand over acute heart failure in one minute?

The acute heart failure handover gives the gas, the diuretic and the ventilation decision. Situation: a 74 year old with acute pulmonary oedema, saturations 86 per cent on arrival. Background: ischaemic cardiomyopathy, stopped furosemide a week ago. Assessment: NT-proBNP raised, ECG sinus tachycardia without new ischaemia, pH 7.28 with severe dyspnoea, so CPAP started and intravenous furosemide given; blood pressure 150 systolic. Recommendation: hourly urine output and observations, repeat gas in one hour, critical care aware, echo requested for tomorrow, please call if the pH or saturations fall or he tires.

What does the panel listen for in a heart failure answer?

The panel listens for the natriuretic peptide thresholds, diuretic as the only routine drug, the do-not-routinely list, the NIV criteria of severe dyspnoea with acidaemia, and the plan to keep the beta-blocker. That said, the sentence that separates candidates is about discharge: ACE inhibitor and aldosterone antagonist started in hospital, and a specialist review within 2 weeks. The internalmedicineinterview bank of 361 questions with AI-marked spoken practice rehearses that full arc.

What are the common mistakes in a heart failure station?

  • Morphine and a GTN infusion as reflex first-line drugs
  • Stopping the beta-blocker in a patient who is not bradycardic, blocked or shocked
  • Withholding NIV from an acidaemic, exhausted patient because it is not routine
  • Diuresing without hourly urine output, weight and renal function
  • Discharging without prognostic medicines or a 2-week specialist follow-up

How this comes up at the IMT interview

Acute heart failure maps onto the IMT clinical station as a precision test. Investigations and diagnosis is the natriuretic peptide rule-out and the echo within 48 hours; management is intravenous diuretic, the precipitant, and the list of drugs NICE says not to give routinely; communication is explaining diuresis, fluid restriction and the new medicines to the patient. The handover minute is scored on the gas, the ventilation decision and the named trigger for calling critical care.