Steinhart Model for Acute Heart Failure in Undifferentiated Dyspnoea
Clinical prediction rule developed in the emergency department to diagnose acute heart failure (AHF) in adults presenting with acute dyspnoea when BNP is unavailable. Based on history and physical examination.
Score interpretation
Steinhart < 6 -- acute heart failure unlikely; other causes of dyspnoea should be pursued
→ Consider alternative diagnoses: AECOPD/asthma (salbutamol 5 mg nebulised, ipratropium 0.5 mg, prednisolone 40 mg); pulmonary embolism (Wells score, D-dimer, CTPA if indicated); pneumonia (CURB-65, antibiotic based on severity); pneumothorax (CXR, needle decompression); anaemia (FBC, transfusion if haemodynamically compromised); BNP/NT-proBNP to supplement clinical assessment; echocardiography if clinical uncertainty.
Steinhart 6-10 -- moderate probability; AHF workup alongside alternative diagnoses
→ Urgent BNP or NT-proBNP; echocardiogram (bedside POCUS for B-lines, LV function, IVC); ECG (AF, LBBB, ischaemia); CXR (if not done); ABG; FBC, U+E, troponin; if BNP elevated: treat as AHF; furosemide 40-80 mg IV; oxygen if SpO2 < 94%; CPAP/NIV if severe (CPAP 5-10 cmH2O); sitting position; BP management; refer cardiology.
Steinhart > 10 -- acute heart failure highly likely; begin AHF treatment immediately
→ Immediate AHF management: oxygen if SpO2 < 90%; CPAP (PEEP 5-10 cmH2O) if respiratory distress -- CPAP-AHF trial: reduces intubation; furosemide IV 40-80 mg (or 1-2.5x regular oral dose if already on furosemide); GTN infusion if SBP > 110 mmHg (20-200 mcg/min titrated for dyspnoea relief); morphine with caution (recent data suggest caution -- may worsen outcomes); Foley catheter for urine output monitoring (target > 0.5 mL/kg/hour); BNP-guided therapy; echocardiogram for EF; consider ARNI/SGLT2i optimisation; cardiogenic shock triggers (MAP < 65, cold peripheries, UO < 0.5 mL/kg/h): vasopressor and MCS assessment.
Interpretation bands for the Steinhart AHF Model. Apply clinical judgement and local guidance.
References
- Steinhart BD et al. Sensitivity of a validated clinical prediction rule vs. BNP for suspected acute heart failure in patients presenting to the emergency department. Ann Emerg Med. 2009;54(4):567-573.
- McDonagh TA et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726.
Related
Curated clinical cross-links plus same-class fallbacks.
- Acute Heart Failure · ESC 2021 Heart Failure Guidelines; NICE NG106
- NSTEMI / Unstable Angina · ESC 2020 NSTEMI Guidelines; NICE NG185
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
- Hypertensive Emergency · ESC/ESH 2018 Hypertension Guidelines; NICE NG136
- Bradycardia Management · Resuscitation Council UK ABCDE; ESC 2021 Pacing Guidelines
- Ventricular Tachycardia / Fibrillation · Resuscitation Council UK ACLS; ESC 2022 Ventricular Arrhythmia Guidelines
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.