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