Optimal Diuretic Therapies for Acute Heart Failure With Volume Overload

Inclusion Criteria: 1. Age ≥ 18 years 2. Acute hospital admission with a clinical diagnosis of acute heart failure with volume overload. 3. Display risk of diuretic resistance, characterized by: 1. Daily loop-diuretics administration for a minimum of 7 days before admission, or 2. Insufficient decongestion observed in the preceding 24 hours (weight reduction \<500g or negative fluid balance \<1L) despite being treated with high-dose IV loop diuretic (equivalent to ≥120 mg IV furosemide within 24 hours). 4. Clinical signs of congestion, indicated by one or more of the following: pitting peripheral edema, ascites, elevated jugular venous pressure, or radiological/ultrasonic evidence of pulmonary congestion. Exclusion Criteria: 1. Acute coronary syndrome 2. Systolic blood pressure \<85 mmHg 3. Use of renal replacement therapy or ultrafiltration in-hospital before study inclusion 4. Treatment with acetazolamide or metolazone during the index hospitalization prior to randomization 5. Known allergy to any of the used drugs 6. Severe hypokalemia (\<2.5 mmol/l) or severe hyponatremia (\<125 mmol/l) 7. Severe hepatic impairment defined as an INR \>1.5 (not due to anticoagulant therapy) and/or a Child-Pugh score ≥B7 8. Known pregnancy