OSCE — assessment of acute decompensated heart failure · MBBS OSCE

Brief (to candidate)

A 68-year-old man with known heart failure and a prior MI is brought to the emergency department with two hours of sudden severe breathlessness. He cannot lie flat, is coughing pink frothy sputum, and looks distressed. RR 34, SpO2 84% on air, BP 170/96, HR 110 in atrial fibrillation, bilateral widespread crackles. You have 8 minutes to assess him, give the immediate management with doses, identify the precipitant, and outline the definitive plan including the four pillars of his heart failure.

Candidate instructions

Take a focused, structured history and examine using an ABCDE approach.
Give the immediate management of acute pulmonary oedema with drugs and doses.
Identify and treat the precipitant.
Outline the definitive management of his (reduced-EF) heart failure — the four pillars with agents and target doses — and the monitoring required.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
ABCDE / resuscitation	Sit upright; high-flow oxygen titrated to correct hypoxia; IV furosemide 40-80 mg; nitrate/GTN infusion (BP permits); CPAP/non-invasive ventilation; IV access, ECG, bloods
Identify precipitant	Recognises new fast atrial fibrillation (and checks for ischaemia, infection, non-adherence, NSAIDs); arranges rate control appropriate to the congested state
Classification	States heart-failure syndrome; HFrEF (reduced EF); notes NYHA IV (symptomatic at rest) and ACC/AHA stage C/D
Definitive — four pillars	Names ARNI/ACE-inhibitor, beta-blocker, MRA, SGLT2 inhibitor; gives target doses (e.g. sacubitril/valsartan 97/103 mg BD; bisoprolol 10 mg OD; spironolactone 25-50 mg OD; dapagliflozin 10 mg OD)^[1]
Rules of use	Beta-blocker start low/go slow, only once euvolaemic; 36-hour ACEi-to-ARNI washout; monitor K+ and creatinine on RAAS/MRA
Investigations	Echocardiogram (pivotal — LVEF), BNP/NT-proBNP, ECG, CXR (cardiomegaly, Kerley B lines, bat-wing oedema), U&E, troponin
Communication & safety-net	Clear plan; ICU/HDU consideration; decongest then transition to oral GDMT; early outpatient review; weight and salt/fluid advice

Model key actions

Immediate: upright, oxygen, IV furosemide 40-80 mg, nitrate, CPAP; identify and treat the precipitant (rate-control the AF, check for ischaemia/infection).^[1]
Once euvolaemic and stable, establish all four foundational therapies of HFrEF and uptitrate to target doses — in MERIT-HF metoprolol CR/XL was titrated over 6 to 8 weeks to a target of 200 mg once daily and improved survival; defer beta-blocker initiation until decongested.^[1]^[2]
Confirm the EF with echocardiography (HFrEF), check K+/creatinine before and after each RAAS/MRA change, and assess for device therapy (ICD for primary prevention; CRT if QRS wide).^[1]
Treat the ischaemic cause (antiplatelets, statin); arrange early outpatient review.

Common errors

Giving a beta-blocker in the acute congested state (negative inotrope — can precipitate collapse).
IV fluid bolus for the volume-overloaded patient (worsens pulmonary oedema).
Not identifying/treating the precipitant (here, the fast AF).
Listing all four pillars without doses, the start-low/go-slow rule, or the 36-hour washout.
Applying HFpEF logic (SGLT2i only) to an HFrEF patient, or vice versa.

References2Show

[1]McDonagh TA, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 2021.PMID 34447992
[2]Hjalmarson A, et al. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). MERIT-HF Study Group. JAMA, 2000.PMID 10714728