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.................................................... 11.3 Management 11.3.1 General aspects Management can be subdivided in three stages (pre-hospital, in-hospital, and pre-discharge), having different goals and requiring different approaches (Figure 11).

Pre-hospital phase In the pre-hospital setting, AHF patients should benefit from noninvasive monitoring, including pulse oximetry, BP, heart rate respiratory rate, and a continuous ECG, instituted within minutes of patient contact and in the ambulance if possible.305 Oxygen therapy may be given based on clinical judgment unless oxygen saturation is <90% in which case it should be administered. In patients with respiratory distress, respiratory rate >25 breaths/min, oxygen saturation <90%, non-invasive ventilation should be initiated.444,448 Although therapeutic tools may be available in the prehospital setting, whether more effective pre-hospital care would alter the clinical outcome remains to be proven in randomized clinical trials.455 Furthermore, prehospital management should not delay the rapid transfer of AHF patients to the most appropriate medical setting.455,456

In-hospital management Diagnostic workup and appropriate pharmacological and nonpharmacological treatment must be started promptly and in parallel (Figure 12). AHF patients are triaged to the appropriate level of care according to the degree of haemodynamic instability and severity of the critical illness. Disposition decisions are important components of the initial phase of management (see Supplementary text 11.2 and Supplementary Tables 1719). The type and intensity of in-hospital monitoring depends on clinical severity, settings of care and in-hospital course (see Supplementary text 11.3). As AHF is a heterogeneous condition, management may differ according to the main clinical presentation. Management starts with the search for specific causes of AHF.1,305,430 These include

Management of patients with pulmonary oedema

SBP ≥110 mmHg

Loop diuretics (Class I)

and/or vasodilators

(Class IIb) N

Y N

Y

Signs of hypoperfusion

Loop diuretics (Class I) and inotropes/vasopressors

(Class IIb) Loop diuretics

(Class I)

Congestion relief N Y

Medical therapy optimization

(Class I)

Consider RRT, MCS, other devices (Class IIa)

OR

Consider palliative care Oxygen (Class I) or

ventilatory support

(Class IIa)

Figure 8 Management of pulmonary oedema. MCS= mechanical circulatory support; RRT= renal replacement therapy; SBP=systolic blood pressure. Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026