From Clinical guidelines — Diagnosis and treatment manual › Chapter 12: Other conditions · Médecins Sans Frontières, April 2021 update
MSF diagnostic and treatment protocol for acute heart failure and acute pulmonary oedema in resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- April 2021 update
- Audience
- Physicians, emergency care providers, clinical officers in MSF field settings
- Evidence
- Evidence-based recommendations adapted from ESC 2016 and Canadian Cardiovascular Society 2017 guidelines
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline provides a practical protocol for the diagnosis and management of acute heart failure (acute pulmonary oedema) in humanitarian and resource-limited settings. The guideline emphasises clinical diagnosis based on sudden-onset dyspnoea, bilateral peripheral oedema, elevated jugular venous pressure, and pulmonary crepitations, with clearly defined signs of severity including systolic blood pressure <90 mmHg, SpO₂ 130 or 30 or <12/minute.
Management is stratified by systolic blood pressure. For patients with systolic BP ≥90 mmHg, the guideline recommends semi-seated positioning, oxygen to maintain SpO₂ ≥95%, intravenous furosemide 40–80 mg (with dose adjustment for patients already on diuretics), and short-acting nitrates (isosorbide dinitrate or glyceryl trinitrate) if systolic BP >100 mmHg. Non-invasive ventilation with CPAP is recommended for persistent hypoxaemia when monitoring is available.
The protocol integrates point-of-care ultrasound (POCUS) where trained clinicians are available, with 12-zone lung examination and 5-view cardiac examination. All patients require hospitalisation with monitoring of vital signs, mental status, and urine output, followed by treatment of underlying pathology such as chronic heart failure, hypertension, or acute coronary syndrome.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Signs of severity: SpO₂ <90%, systolic BP <90 mmHg (cardiogenic shock), heart rate >130 or <40/minute, respiratory rate >30 or <12/minute
- For systolic BP ≥90 mmHg: administer furosemide IV 40–80 mg, repeated as necessary according to urine output and respiratory status
- If patient already taking furosemide >40 mg, administer pre-existing dose by IV route
- Administer oxygen to maintain SpO₂ ≥95%; if pulse oximetry unavailable, give 6–10 litres/minute to hypoxic patients
- Add short-acting nitrate if systolic BP >100 mmHg: isosorbide dinitrate 5 mg sublingual (up to 2 doses 10 minutes apart) or glyceryl trinitrate 0.5 mg sublingual (up to 3 doses 5 minutes apart)
- Isosorbide dinitrate IV: 2 mg slow IV injection over 2 minutes, then 2–10 mg/hour continuous infusion with electric syringe pump
- Target systolic BP 120–150 mmHg and diastolic BP <110 mmHg if baseline unknown
- Non-invasive ventilation (CPAP) recommended for persistent hypoxaemia unless contraindicated (impaired consciousness)
Treatment protocol by blood pressure status
Table extracted from the guideline
| Systolic blood pressure | Management | Specific interventions |
|---|---|---|
| <90 mmHg | Cardiogenic shock | See Shock protocol (Chapter 1) |
| ≥90 mmHg | Standard acute heart failure protocol | Semi-seated position; oxygen to SpO₂ ≥95%; furosemide IV 40–80 mg; monitor HR, RR, BP, SpO₂, mental status, urine output |
| ≥90 mmHg with volume overload | Add diuretic | Furosemide IV 40–80 mg (or pre-existing dose if >40 mg), repeat according to urine output |
| >100 mmHg | Add vasodilator | Isosorbide dinitrate 5 mg sublingual (up to 2 doses, 10 min apart) or 2 mg IV then 2–10 mg/hr infusion; OR glyceryl trinitrate 0.5 mg sublingual (up to 3 doses, 5 min apart) |
Source: Médecins Sans Frontières, Acute heart failure (acute pulmonary oedema) — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“In patients with SpO2 < 90%, administer oxygen with a mask at the necessary flow rate to maintain SpO2 ≥ 95%.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise the critical importance of this MSF protocol for Georgian clinicians managing cardiovascular emergencies, particularly in district hospitals where acute heart failure is common but resources are limited. The protocol's clarity on furosemide dosing—40 to 80 mg IV initially, or the patient's pre-existing dose if higher—and the specific blood pressure threshold of 100 mmHg for adding nitrates provides actionable guidance that can reduce clinical uncertainty in emergency situations. One implementation challenge for Georgia will be ensuring consistent availability of pulse oximetry and oxygen delivery systems across all emergency departments, particularly in rural areas, as the protocol appropriately emphasises SpO₂ monitoring as a cornerstone of management and titration of therapy. The integration of POCUS, when trained clinicians are available, aligns well with Georgia's efforts to modernise emergency medicine, though systematic training programmes will be essential before widespread adoption.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
Acute heart failure management is highly relevant for Georgia and the South Caucasus, where cardiovascular disease remains the leading cause of mortality. This MSF protocol is particularly applicable to district hospitals and rural settings where advanced cardiac care may be limited. Georgian healthcare facilities implementing this guideline would need to ensure availability of furosemide, short-acting nitrates, pulse oximetry, and oxygen delivery systems. The protocol’s emphasis on clinical diagnosis is appropriate for settings with limited access to echocardiography and cardiac biomarkers. National cardiology programmes should consider integrating POCUS training for emergency physicians and developing referral pathways for subsequent management of underlying cardiac pathology, particularly given the high prevalence of hypertension and ischaemic heart disease in the region.
Questions this guideline answers
Quick answers
When should I add nitrates to the treatment of acute heart failure?
Add a short-acting nitrate (isosorbide dinitrate or glyceryl trinitrate) only if systolic blood pressure is >100 mmHg. The aim is to gradually lower systolic BP to near-baseline value (or 120–150 mmHg if baseline unknown, with diastolic <110 mmHg). Do not give nitrates if systolic BP is ≤100 mmHg due to risk of hypotension.
How much furosemide should I give if the patient is already taking it chronically?
If the patient was already taking furosemide at doses >40 mg, administer the pre-existing dose by the IV route. For patients not on furosemide or on doses ≤40 mg, give 40–80 mg IV, which may be repeated if necessary according to urine output, signs of respiratory distress, and SpO₂.
What oxygen target should I aim for in acute pulmonary oedema?
Maintain SpO₂ ≥95% using oxygen with a mask at the necessary flow rate. If pulse oximetry is not available, administer oxygen at 6–10 litres/minute to patients with signs of hypoxia. All patients with SpO₂ <90% should receive oxygen.
When should I consider CPAP for a patient with acute heart failure?
Non-invasive ventilation using CPAP is recommended in patients with persistent hypoxaemia despite standard treatment, unless contraindicated (e.g. impaired consciousness) and only if appropriate monitoring is available. CPAP should not be used in patients with reduced consciousness.
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- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 12: Other conditions
- Type
- Clinical guideline (chapter)
- Edition
- April 2021 update
- Status
- Current
- Published
- 2026-10-14
- Languages
- English, French
- Scope
- Diagnosis and treatment of acute heart failure (acute pulmonary oedema) in humanitarian and resource-limited settings
- Audience
- Physicians, emergency care providers, clinical officers in MSF field settings
- Evidence
- Evidence-based recommendations adapted from ESC 2016 and Canadian Cardiovascular Society 2017 guidelines
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Acute heart failure (acute pulmonary oedema). In: Clinical guidelines — Diagnosis and treatment manual. Chapter 12: Other conditions. Paris: MSF; 2021 Apr.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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