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Cardiology
Cardiology

Managing Acute Decompensated Heart Failure on the Ward

A practical ward-level framework for the patient with acute decompensated heart failure — assessment, diuresis, and the early decisions that matter most.

Published
20 May 2026
Read time
3 min read
Clinical ReviewFoundation / Junior DoctorSpecialty Trainee

The middle-of-the-night referral for "leg swelling and shortness of breath" is one of the most common cardiology takes. The decisions you make in the first two hours — particularly around diuresis and oxygenation — shape the next seventy-two.

Recognise the pattern

Acute decompensated heart failure (ADHF) is congestion, not necessarily low cardiac output. The two questions to answer at the bedside are:

  1. Wet or dry? Crackles, raised JVP, peripheral oedema, hepatomegaly.
  2. Warm or cold? Pulse pressure, capillary refill, mottling, mentation.

The four resulting profiles (warm-and-wet, cold-and-wet, cold-and-dry, warm-and-dry) drive everything that follows. The vast majority of ward admissions are warm-and-wet — the focus is decongestion.

Clinical pearl

A normal BNP makes ADHF very unlikely. A markedly raised BNP makes it likely but does not prove congestion is the dominant problem — consider sepsis, AKI, and PE in parallel.

First-hour priorities

  • Oxygenation: titrate to SpO2 94-98% (88-92% if CO2 retention is a concern). Sit the patient up.
  • Monitoring: continuous SpO2, three-lead ECG, urine output (consider catheterisation early — you'll be following diuresis closely).
  • Bloods: FBC, U&E, LFTs, troponin, BNP/NT-proBNP, ABG if respiratory distress.
  • Imaging: portable chest X-ray; bedside lung ultrasound if available — multiple B-lines confirm pulmonary congestion.

Diuresis

The DOSE trial showed no advantage of high-dose over low-dose furosemide, but a clear signal that intravenous beats oral in the acute phase.

Evidence

Start with at least 1.0× the patient's usual home dose, given intravenously. A patient on 40 mg PO furosemide at home should not receive less than 40 mg IV — and typically benefits from 80 mg IV as a starting bolus.

Furosemide40-80 mgIV

Reassess at 2-6 hours. The two questions:

  • Is urine output >150 mL/h?
  • Has weight dropped, or oedema visibly improved?

If not, double the dose (don't add a thiazide yet — escalate the loop first). If still resistant after dose escalation, consider a continuous infusion or thiazide combination (e.g. bendroflumethiazide 5 mg PO or metolazone 2.5-5 mg PO 30 minutes before each furosemide dose).

Red flag

SBP <90 mmHg with cool peripheries or worsening renal function on diuretics — this is cardiogenic shock or pre-shock. Stop aggressive diuresis, escalate to senior review, and consider transfer to a level-2 bed. Inotropes and vasoactive support may be needed.

Don't forget the chronic disease

ADHF is usually a flare of chronic heart failure. Once the patient is decongesting, focus on what's missing from their regimen:

  • ACEi/ARB or ARNi
  • Beta-blocker (don't stop one in acute decompensation; reduce only if symptomatic bradycardia or hypotension)
  • MRA (spironolactone or eplerenone)
  • SGLT2 inhibitor (dapagliflozin or empagliflozin) — now part of four-pillar therapy for HFrEF irrespective of diabetes status

Key points

  • ADHF is usually warm-and-wet congestion — diuresis is the lever.
  • Start IV loop diuretic at ≥1× home dose. Reassess at 2-6 hours.
  • Watch SBP and renal function closely; cool peripheries change the plan.
  • Don't leave hospital without the four-pillar therapy review.

Discharge criteria

  • Stable on oral diuretic for 24-48 hours
  • Weight at or near euvolaemic baseline
  • Renal function stable
  • Four-pillar therapy reviewed and initiated/up-titrated
  • Heart failure nurse follow-up arranged within 2 weeks

Most of the work to prevent the next admission happens after the acute decongestion. The discharge consultation is the moment to set up a community heart failure team review, organise echocardiography if not done in the last 12 months, and have an honest conversation about the disease trajectory.

References

  1. [1]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. Link
  2. [2]Felker GM, Lee KL, Bull DA, et al. Diuretic strategies in patients with acute decompensated heart failure (DOSE-AHF). N Engl J Med. 2011;364(9):797-805. Link

About the author

Dr. Imani OkoroVerifiedVerified medical practitioner

MBBS, MRCP, PhD

Cardiology· Imperial College Healthcare NHS Trust

Consultant cardiologist with a research interest in heart failure pharmacotherapy and remote monitoring. Edits the cardiology stream for MedSchool.

ORCID 0000-0001-2345-6789

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