Acute left ventricular failure (LVF) is the failure of left ventricle to propel blood in the systemic
circulation. As a result, there is accumulation of blood in pulmonary circulation resulting in
pulmonary oedema (Table 2).

Causes of LVF (Pulmonary Oedema)

• Systemic hypertension.
• Acute myocardial infarction.
• Aortic valvular disease (stenosis and regurgitation).
• Mitral regurgitation.
• Cardiomyopathy.
• Coarctation of aorta.
• Rapid or excess infusion of fluid or blood or plasma.
• Hyperdynamic circulation.


• Breathlessness, may be orthopnoea.
• Cough with frothy sputum, occasional haemoptysis.
• Palpitation.
• Features of low cardiac output—restlessness, sweating, oliguria.


• Patient looks dyspnoeic with propped up position.
• Cyanosis.
• Pulse—tachycardia, may be pulsus alternans.
• BP—low but may be high if the patient is hypertensive.

Precordium Examination:
• Apex beat—may be shifted, thrusting or heaving in character.
• On auscultation—Gallop rhythm (tachycardia with 3rd or 4th heart sound. It resembles the
sound produced by galloping horse).

• In lungs—bilateral basal crepitations.
• Signs of primary cause may be present.

Cardinal Features of LVF

• Bilateral basal crepitations.
• Gallop rhythm.
• Pulsus alternans.


• Chest X-ray—shows pulmonary oedema (perihilar bats wing appearance, Kerleys B line,
• ECG—may show myocardial infarction, LVH.
• Echocardiogram.

Treatment of Acute LVF (Pulmonary Oedema)

• Bed rest.
• Propped up position.
• High-flow oxygen inhalation (60–100%).
• Diuretic—frusemide IV 80–120 mg. May be repeated.
• Morphine (if no contraindication, such as bronchial asthma, COPD, emphysema, chronic
bronchitis)—10–20 mg IV slowly with antiemetic metochlopramide or cyclizine.
• ACE inhibitor—ramipril, captopril, enalapril.
• If no response, inotropic agents like dopamine, dobutamine may be added.
• Treatment of primary cause.
• Antiarrhythmic drug, if arrhythmia.