New Decongestion Strategies in an Evolving Heart Failure Landscape

This editorial reviews the evolving landscape of volume management in heart failure, spotlighting the ADVOR trial and its evaluation of acetazolamide a carbonic anhydrase inhibitor targeting the proximal renal tubule as adjunct therapy to loop diuretics. The trial demonstrated improved early decongestion and reduced hospital stay with acetazolamide, though effects on rehospitalization remained unclear. The author contextualizes acetazolamide’s mechanism relative to thiazides, metolazone, and high-dose spironolactone, proposing its favorable safety profile. Notably, the trial excluded patients on SGLT2 inhibitors, limiting applicability to contemporary practice where these agents are standard. Because both SGLT2 inhibitors and acetazolamide act proximally, their combined or comparative efficacy warrants future investigation. The piece emphasizes individualized treatment based on diuretic responsiveness and advocates further trials comparing nephron-targeting strategies. Clinicians are encouraged to consider acetazolamide for patients with loop diuretic resistance, acknowledging the need for additional research in SGLT2-integrated care.

This editorial reviews the evolving landscape of volume management in heart failure, spotlighting the ADVOR trial and its evaluation of acetazolamide a carbonic anhydrase inhibitor targeting the proximal renal tubule as adjunct therapy to loop diuretics. The trial demonstrated improved early decongestion and reduced hospital stay with acetazolamide, though effects on rehospitalization remained unclear. The author contextualizes acetazolamide’s mechanism relative to thiazides, metolazone, and high-dose spironolactone, proposing its favorable safety profile. Notably, the trial excluded patients on SGLT2 inhibitors, limiting applicability to contemporary practice where these agents are standard. Because both SGLT2 inhibitors and acetazolamide act proximally, their combined or comparative efficacy warrants future investigation. The piece emphasizes individualized treatment based on diuretic responsiveness and advocates further trials comparing nephron-targeting strategies. Clinicians are encouraged to consider acetazolamide for patients with loop diuretic resistance, acknowledging the need for additional research in SGLT2-integrated care.