Sudden breathlessness needs urgent attention and vigorous treatment, followed by checks says Dr Mel Wynne-Jones


Heart failure occurs when blood cannot be pumped effectively enough ©iStock

Acute heart failure (AHF) is the most common cause of hospital admissions, with more than 67,000 a year in England and Wales.

And although it’s more likely as we get older, young people can be affected too.

AHF doesn’t mean the heart has stopped (although this may happen), and although it’s caused by many of the same conditions as chronic heart failure (which gradually produces breathlessness and ankle swelling), AHF is much more dramatic and scary.

However, NICE, the National Institute for health and Care Excellence, says diagnosis and treatment can vary, depending on our age and where we live.

So it has produced new guidelines to standardise best care, reduce mortality and improve patients’ quality of life.

What is it?

AHF means that your heart suddenly can’t pump blood effectively enough; it’s a medical emergency.

It can be triggered by many heart conditions, including heart attacks or coronary artery disease, leaky/narrowed valves, abnormal rhythms, heart muscle damage (including genetic, infection or from drugs), very high blood pressure or a blood clot affecting the lungs.

It can also develop at high altitude, in severe anaemia, thyroid disease or sepsis, or in someone who already has chronic heart failure.

Either or both sides of the heart may be affected, leading to a backlog of blood. In left heart failure (also known as pulmonary oedema), fluid leaks into the lungs, so they become waterlogged and stiff. In right heart failure, fluid backs up into the liver and legs.

The symptoms

You may initially notice breathlessness or coughing at night or when lying flat. But AHF can suddenly develop, often during sleep, producing severe breathlessness, wheezing, sweating, faintness, a rapid heartbeat, low blood pressure and cough with pink frothy sputum.

You may look very pale or even blue (low oxygen levels) and will need to sit upright.

Right heart failure produces leg swelling (oedema), weight gain, discomfort under the ribs, nausea, and even jaundice.


You’ll need to call 999; you can be treated with oxygen in the ambulance and a tube (cannula) will be inserted into your vein so that drugs can be given easily.

Once in hospital, NICE says you should be placed in the care of a specialist heart failure team within 24 hours.

The underlying cause of your HF will need treatment. If this is heart disease, you’ll be given intravenous drugs to improve your heart’s blood supply (nitrates) and make your kidneys excrete excess fluid (diuretics).

Other causes will need appropriate treatment too.

Later you’ll be prescribed a beta blocker (names end in –olol) and an ACE inhibitor (names end in –pril) to help your heart beat more efficiently. If your heart is really struggling you may need temporary drugs or equipment to support your circulation in the intensive care unit.

Once you’re better and discharged, you’ll be referred to the community heart failure service for rehabilitation and regular checks.

5 tests you will need for AHF

1 Blood test for the protein BNP (B‑type natriuretic peptide), that helps to make the diagnosis and rule out other causes of breathlessness.

2 Blood tests for anaemia, thyroid disease, blood oxygen/chemical levels, and liver and kidney function (your urine flow will also be monitored).

3 A heart tracing (ECG) to check for heart damage and abnormal rhythms.

4 A chest X-ray to look for other causes of symptoms.

5An echocardiogram (heart scan) within 48 hours to look for underlying causes, and see how efficiently your heart muscles are pumping.