Algorithm
- ABC; sit upright if possible; continuous SpO₂/ECG/BP; identify wet vs dry and warm vs cold profiles.
- Oxygen if SpO₂ <90%; start non-invasive ventilation early (CPAP or BiPAP) in respiratory distress / flash edema unless contraindicated (vomiting, GCS↓, shock needing intubation).
- IV loop diuretic if congestion/volume overload (e.g. furosemide); continue chronic loop IV if already on diuretics (often ≥ usual oral dose).
- Vasodilators (nitrates) if hypertensive / severe congestion and SBP usually >110 mmHg — avoid if hypotensive or severe AS suspicion.
- If cardiogenic shock (cold + hypotensive): cautious fluids only if clear hypovolemia; noradrenaline often first vasopressor; consider inotrope (dobutamine/levosimendan) per local protocol; urgent cardiology / mechanical support pathway.
- Urgent ECG: treat ACS, arrhythmia, hypertensive emergency as cause; chest X-ray / POCUS for congestion vs alternative diagnoses.
Red flags
- • Cardiogenic shock — not diuretic alone
- • RV infarct / tamponade / PE mimics
- • Hypotension on nitrates
- • Need intubation if exhaustion / vomiting / low GCS
Medications by step
Respiratory support
- Oxygen · inhaled
Titrate SpO₂ ≥90–94% (avoid hyperoxia)
- CPAP / BiPAP (NIV) · NIV
Early in flash pulmonary edema / distress
Congestion
- Furosemide · i.v.
20–40 mg IV (or ≥ usual oral dose IV if chronic use)
- Glyceryl trinitrate · s.l. / i.v.
SL or IV infusion if hypertensive congestion
Shock
- Noradrenaline · i.v. infusion
Titrate to perfusion / MAP target
- Dobutamine · i.v. infusion
2.5–10 mcg/kg/min IV if low-output (local protocol)
References
- • ESC — Acute and chronic heart failure / acute HF pathways (2021)
- • ERC / critical care — NIV in cardiogenic pulmonary edema (2025)
Updated: Июль 2026