guidelines

acute heart failure

nice cg187 summary: diagnosis (bnp/nt-probnp rule-out thresholds), early echo, initial iv diuretics, when to avoid nitrates/opioids, escalation (niv/inotropes), and post-discharge follow-up.

last reviewed: 2026-02-14
based on: NICE CG187 (published Oct 2014; last updated 12 Dec 2023)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Rule-out thresholds (new suspected AHF): BNP <100 ng/L or NT-proBNP <300 ng/L makes heart failure unlikely.
  • Early echo: perform transthoracic Doppler 2D echo to confirm cardiac abnormalities; consider within 48 hours of admission for early specialist management.
  • First-line treatment: offer IV diuretic therapy (bolus or infusion). Monitor renal function, weight and urine output closely.
  • Don’t reflexively use: opiates and nitrates are not routine; nitrates only in specific circumstances with close BP monitoring.
  • Follow-up: specialist HF team clinical assessment within 2 weeks of discharge.

Diagnosis & early investigations

  • History, examination and standard investigations (ECG, CXR, bloods) as per chronic HF pathways.
  • Natriuretic peptides: in new suspected AHF use a single BNP/NT-proBNP measurement to help rule out HF at low levels.
  • Echo: confirm cardiac structure/function and guide early specialist decisions.

Initial treatment (CG187: what NICE explicitly states)

  • IV diuretics: offer to all people with AHF; use bolus or infusion strategy. If already on diuretics, consider higher dose than admission dose (unless adherence concerns).
  • Monitoring: renal function, weight, urine output during diuresis.
  • Opiates: do not routinely offer.
  • Nitrates: do not routinely offer; if used (e.g., concomitant ischaemia, severe hypertension, significant regurgitant valve disease), monitor closely in a suitable care setting.
  • Ventilation: NIV is not routine; consider NIV without delay in cardiogenic pulmonary oedema with severe dyspnoea and acidaemia or if failing medical therapy.
  • Inotropes/vasopressors: not routine; consider only for potentially reversible cardiogenic shock in a high-dependency/cardiac care environment.

After stabilisation & discharge coordination

  • Continue beta-blockers if already prescribed unless HR <50, 2nd/3rd degree AV block, or shock.
  • Restart/initiate evidence-based therapies during admission once stable (specialist-led).
  • Follow-up standard: HF specialist team assessment within 2 weeks after discharge; ensure primary care monitoring plan is explicit.

References (Harvard):

  • NICE (2023) Acute heart failure: diagnosis and management (CG187). https://www.nice.org.uk/guidance/cg187

FAQs

What BNP/NT-proBNP values help rule out HF in acute presentations?
CG187: BNP <100 ng/L or NT-proBNP <300 ng/L can help rule out HF in new suspected acute heart failure.
Do I give nitrates to everyone with pulmonary oedema?
No. NICE says do not routinely offer nitrates; reserve for specific indications and monitor closely.
What follow-up should I enforce from hospital?
A specialist heart failure team clinical assessment within 2 weeks of discharge.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.