Randomized Controlled Trial of urinE chemiStry Guided aCute heArt faiLure treATmEnt (ESCALATE)

Inclusion Criteria: * Age \> 18 * Emergency Department diagnosis of Acute Heart Failure (AHF) * Any one of the following: i. Chest radiograph or lung ultrasound consistent with AHF ii. Jugular venous distension iii. Pulmonary rales on auscultation iv. Lower extremity edema v. S3 gallop * \> 10 pounds of volume overload physician estimate or historical dry weight * IV diuretic ordered or planned to be during first 24 hours of ED or inpatient stay Exclusion Criteria: * End Stage Renal Disease (ESRD) requiring dialysis * Need for immediate intubation * Acute Coronary Syndrome - presentation consistent with myocardial ischemia AND new ST-Segment elevation/depression * Temperature \> 100.5ºF * End Stage Heart Failure: transplant list or ventricular assist device * Concurrent use of ototoxic medications including intravenous aminoglycosides and cisplatin * Systolic Blood Pressure \< 90 mmHg at time of consent * LV outflow obstruction, severe uncorrected stenotic valvular disease or severe restrictive cardiomyopathy * Greater than 2 doses of IV diuretic administered at the time of screening from the time of the hospital presentation leading to this admission (outside hospital time is included) * Severe, uncorrected serum electrolyte abnormalities at the time of consent (serum potassium \<3.0 mEq/L, magnesium \<1.0 mEq/L or sodium \<125 or \>150 mEq/l) * Lack of informed consent