Who / when
- Adults with breathlessness on exertion, breathlessness lying flat or waking them at night, tiredness, or swelling of both legs or the abdomen.
- People with high BP, rheumatic heart disease, previous heart attack, kidney disease, HIV, or a recent pregnancy (heart failure in the last month of pregnancy or within 6 months of birth suggests peripartum cardiomyopathy).
- People already known to have heart failure, at every review.
Red flags: refer now
- Breathless at rest, respiratory rate over 30 per minute, or SpO2 below 90%.
- Crackles across both lungs, frothy sputum, or unable to lie flat.
- Systolic BP below 90, cold hands and feet, confusion or drowsiness.
- Chest pain, fainting, a very fast or very slow pulse.
- Fever with a new murmur (endocarditis); pregnancy or recent birth.
Acute pulmonary oedema: treat and transferSit the person upright. Oxygen if SpO2 is below 90%. Furosemide 20 mg IV if not already on it, or their usual oral dose given IV; expect urine within 30 minutes. If systolic BP is below 90, do not give diuretic: refer urgently.
Assess
- Pulse (rate and rhythm: irregular suggests atrial fibrillation), BP, respiratory rate, SpO2, weight.
- Raised neck veins, crackles, enlarged liver, ascites, swelling of both legs; heart murmurs and extra sounds.
- Look for triggers: stopped medicines, salt or fluid excess, infection, anaemia, fast irregular pulse, uncontrolled BP, NSAIDs.
- Tests where available: creatinine, potassium, haemoglobin, HIV test, glucose, ECG, chest X-ray. Echocardiography (including basic point-of-care ultrasound) confirms the diagnosis and the cause.
Classify
Symptom classes follow the familiar New York Heart Association (NYHA) grading: I none, II on ordinary activity, III on less than ordinary activity, IV at rest.| Picture | Classify as | Action |
|---|
| Breathless at rest, crackles, SpO2 below 90% or low BP | Acute heart failure (pulmonary oedema) | Treat now and refer urgently |
| Breathless on mild exertion, or new swelling and weight gain | Worsening heart failure | Increase diuretic, find the trigger, review in days |
| Breathless only on more than ordinary activity | Mild heart failure | Full treatment, refer once for diagnosis of the cause |
| No symptoms on treatment | Stable heart failure | Continue treatment; review every 1 to 3 months |
Treat
Use your national formulary for doses. The WHO Essential Medicines List includes furosemide, an ACE inhibitor (enalapril), bisoprolol, spironolactone, hydrochlorothiazide and digoxin for heart failure.
Furosemide and enalapril doses from the WHO IMAI district clinician manual (2011). Increase one medicine at a time.| Medicine | Use | Notes |
|---|
| Furosemide (loop diuretic) | For congestion: oral 20 to 40 mg each morning, increased if needed in resistant oedema; lower it once dry | Check potassium and creatinine; watch for dizziness and dehydration |
| Enalapril (ACE inhibitor) | Start low (2.5 mg, at bedtime) and increase slowly | Check creatinine and potassium first; cough; not in pregnancy. ARB if cough |
| Beta-blocker (bisoprolol) | Start at a low dose once stable and not congested; increase slowly | Not in acute heart failure, severe asthma or a slow pulse |
| Spironolactone | Add in moderate to severe heart failure already on an ACE inhibitor and beta-blocker | Risk of high potassium: monitor; avoid in kidney failure |
Treat the cause
- Control BP (HEARTS protocol). Treat anaemia and infection.
- Rheumatic heart disease: secondary prophylaxis with benzathine benzylpenicillin and referral for valve assessment.
- Irregular fast pulse (possible atrial fibrillation): refer for assessment.
- Avoid NSAIDs: they worsen heart failure and kidney function.
Follow-up
- Within a few days after any change in diuretic dose or a hospital stay; then every 1 to 3 months when stable.
- Each visit: symptoms, weight, pulse, BP, neck veins, chest, legs; adherence and supply.
- Creatinine and potassium after starting or increasing an ACE inhibitor, ARB, spironolactone or diuretic, then at least yearly.
- When stable, encourage regular home-based exercise (cardiac rehabilitation).
Counsel
- Weigh yourself every morning if you can. If your weight goes up quickly over a few days, fluid is building up: come back.
- Eat less salt: under 5 g a day. Avoid salty preserved foods.
- Take the tablets every day, even when well; do not stop them without advice.
- Avoid pain tablets such as ibuprofen and diclofenac.
- Stop smoking.
- Women of child-bearing age: plan pregnancy with a health worker; some heart conditions make pregnancy dangerous.
Your heart is weak, so water collects in your lungs and legs. The tablets help your heart and remove the extra water. Weigh yourself each morning and come back if your weight rises quickly or you get more breathless.
When to refer
- Same day: any red flag, or acute pulmonary oedema not improving within 1 to 2 hours.
- Every new case, once, for diagnosis of the cause (echocardiography) where available.
- Suspected rheumatic or congenital heart disease, peripartum cardiomyopathy, or heart failure in pregnancy.
- Not improving despite treatment, or recurrent admissions.
- Potassium above 5.5 mmol/L, or creatinine rising on treatment.
Sources
World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 1. 2011. World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured. 2018. World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. World Health Organization. WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease. 2024. World Health Organization. WHO model formulary for children. 2010. World Health Organization. WHO Model List of Essential Medicines. 2025.