RCT

ADVOR

Acetazolamide in Decompensated Heart Failure with Volume Overload

NEJM, 2022 · Multicenter double-blind randomized placebo-controlled trial (n=519)

Clinical question

Does adding IV acetazolamide to loop diuretics improve successful decongestion in acute decompensated heart failure?

Population: Adults hospitalized with acute decompensated heart failure, volume overload, and elevated BNP/NT-proBNP on chronic oral loop diuretics
Intervention: IV Acetazolamide (500 mg once daily for 3 days) combined with high-dose IV loop diuretics
Comparator: Matching placebo plus high-dose IV loop diuretics
Primary outcome: Successful decongestion defined as absence of volume overload signs at day 3 without escalation of therapy
Result: Successful decongestion was achieved in 42.2% of the acetazolamide group vs 30.5% of the placebo group (risk ratio 1.46; 95% CI, 1.17 to 1.82; P<0.001), with shorter hospital stay (8.8 vs 9.9 days) and greater natriuresis.

What the trial found

Adding IV acetazolamide targeting the proximal tubule improves successful decongestion and speeds hospital discharge in congested acute heart failure.

Current guideline position

Class IIa in ESC 2023 heart failure focused update.

Clinical interpretation

Provides high-quality evidence for sequential nephron blockade using carbonic anhydrase inhibition in loop diuretic resistance.

Clinical Context & Relevant Topics (2)

Disease Reference

Acute Heart Failure & Cardiogenic Congestion

Hemodynamic phenotypes (SCAPE vs ADHF vs Cardiogenic Shock), non-invasive positive pressure ventilation, high-dose vasodilator algorithms, loop diuretics, and sequential nephron blockade.

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Acute Cardiogenic Pulmonary Edema & SCAPE

Hydrostatic pulmonary edema physiology, SCAPE vs decompensated HF vs cardiogenic shock, NIV, titrated vasodilators when hypertensive, diuresis, and sequential nephron blockade.

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