Diuretic Strategies in Acute Heart Failure Patients at High Risk for Diuretic Resistance

Inclusion Criteria: * Elective or emergency hospital admission with clinical diagnosis of acute heart failure * One or more clinical signs of volume overload (i.e., peripheral edema, pleural effusion, jugular venous distension) * Low diuretic efficacy in the first 2 hours after the standard screening dose Furosemide i.v. (i.e., urine volume \< 300 ml and urine sodium concentration \< 70 mmol/L) * Plasma N terminal-proBNP level at enrolment \> 1000 ng/L * Signed Informed Consent form Exclusion Criteria: * Maintenance treatment with Acetazolamide or Metolazone * Use of any non-protocol defined diuretic agent that cannot be stopped upon study inclusion except for sodium-glucose co-transporter-2 inhibitors (e.g., dapagliflozin, empagliflozin, canagliflozin) and mineralocorticoid receptor antagonists (e.g., spironolactone, eplerenone) * Systolic blood pressure \< 90 mmHg * Expected use of intravenous vasopressors (e.g., noradrenaline, adrenaline), inotropes (e.g., dobutamine, milrinone, levosimendan) at any time point during the study * Severe chronic kidney disease (estimated glomerular filtration rate \< 15 ml/min/1.73 m2) or use of renal replacement therapy at any time before study inclusion * Severe liver dysfunction or cirrhosis at risk of hepatic encephalopathy * Severe electrolyte disturbances or metabolic acidosis requiring specific intravenous treatment * Concurrent diagnosis of acute coronary syndrome requiring urgent revascularization * History of cardiac transplanta…