RAAS Optimization for Acute CHF Patients

Inclusion Criteria:

Patients are eligible for enrollment if within the previous 24 hours they were treated with acute decompensated heart failure or diagnosed on the basis of the investigator's clinical diagnosis of heart failure, which needs to be supported by at least 2 the following criteria:

Elevated concentration of B-type natriuretic peptide (BNP) or N-terminal pro-BNP. (Elevated BNP" defined as >300 for sinus rhythm, >500 for patients will atrial fibrillation and elevated pro BNP defined as >1000 for sinus rhythm, >1600 for atrial fibrillation.)
Pulmonary edema on physical examination.
Radiologic pulmonary congestion or edema.
History of Chronic Heart Failure. Anticipated need for IV loop diuretics for at least 48 hours
Willingness to provide informed consent

Exclusion Criteria:

Previously diagnosed end-stage renal disease; Serum Potassium >5.5 mmol/L
Cardiogenic Shock within 48 hours, ST-segment elevation myocardial infarction, ongoing ischemia.
Need for renal replacement therapy through dialysis or ultrafiltration
Myocardial infarction within 30 days of screening.
Patients with systolic blood pressure of less than 90 mm Hg.
Patients requiring Intravenous Vasodilators or inotropic agents (other than Digoxin) for heart failure
BNP less than 250 ng/ml and/or proBNP less than 1000 mg/ml
Pregnant women, prisoners, and institutionalized individuals
Severe stenotic valvular disease
Complex congenital heart disease
Need for mechanical hemodynamic support
Sepsis
Terminal illness (other than HF) with expected survival of less than one year
Previous adverse reaction to the study drugs
Use of IV iodinated radiocontrast material in last 72 hours or planned during hospitalization
Enrollment or planned enrollment in another randomized clinical trial during this hospitalization
Inability to comply with planned study procedures
Primary admission diagnosis other than acute heart failure