Protocol · WHO PEN and PEN-Plus

Heart failure

Heart failure means the heart cannot pump enough blood for the body's needs, so fluid builds up in the lungs and legs. In low-resource settings the common causes are long-standing high blood pressure, rheumatic heart disease, cardiomyopathy (including HIV and peripartum), ischaemic heart disease and kidney disease. Treat the congestion, find and treat the cause, and support the person to stay out of hospital.

Based on WHO PEN and PEN-Plus
For doctors, clinical officers and nurses
Reviewed October 2026

One-page print (A4)

1Who / 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.

Children with heart failure, and suspected congenital heart disease, need referral (PEN-Plus level care).

2Red 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.

3Assess

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.

4Classify

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

5Treat

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.

6Follow-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).

7Counsel

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.

8When 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.

9Sources

World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 1. 2011 (ISBN 9789241548281). Section 3.2.5: causes, signs and management of acute pulmonary oedema (furosemide 20 mg IV or usual oral dose IV; response in 30 minutes; stop diuresis if SBP below 90). Medicine annex: furosemide oral 20 to 80 mg initially, maintenance 20 to 40 mg; enalapril 2.5 mg tablet, start low at bedtime, check renal function and electrolytes first; spironolactone for moderate to severe heart failure on an ACE inhibitor and beta-blocker; hyperkalaemia above 5.5 mmol/L.
World Health Organization and International Committee of the Red Cross. Basic emergency care: approach to the acutely ill and injured. 2018. Recognition of heart failure in the breathless patient.
World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020 (ISBN 9789240009226). Self-care: home-based cardiac rehabilitation.
World Health Organization. WHO guideline on the prevention and diagnosis of rheumatic fever and rheumatic heart disease. 2024. Rheumatic heart disease as a cause; NYHA grading; secondary prophylaxis.
World Health Organization. WHO model formulary for children. 2010. NSAIDs (ibuprofen) may worsen heart failure and kidney function; beta-blocker contraindications (asthma, uncontrolled heart failure, marked bradycardia).
World Health Organization. WHO Model List of Essential Medicines. 2025. Medicines used in heart failure (section 12.4).

Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.