Study: NCT05411991

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Oral chlorthalidone OD
Description: In case of hypernatremia (\>145 mmol/L) or low eGFR (\<30 mL/min/1.73m²), oral chlorthalidone 50 mg OD is added to the diuretic treatment. At any time diuretic resistance is encountered (persistent clinical signs of fluid overload with UNa \<80 mmol/L), oral chlorthalidone is provided at a dose of 100 mg OD. Chlorthalidone is never administered in case of hypotonic hyponatremia with serum sodium concentration \<135 mmol/L.

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Intravenous canrenoate 200 mg OD
Description: At any time diuretic resistance is encountered (persistent clinical signs of fluid overload with UNa \<80 mmol/L), intravenous canrenoate 200 mg OD is provided. Canrenoate is never administered in case of hypotonic hyponatremia with serum sodium concentration \<135 mmol/L or if serum potassium levels are \>5.5 mmol/L. If canrenoate is administered, oral mineralocorticoid receptor drugs are temporarily withhold until switch to oral diuretic treatment.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Maintenance infusion
Description: A maintenance infusion with 500 mL dextrose 5% and 3 g MgSO4 is started at an infusion rate of 20 mL/h upon the moment of first protocol-specified administration of intravenous diuretics and continued until switch to oral diuretic therapy. 40 mmol KCl is added if serum potassium levels are \<4 mmol/L. In case of hypotonic hyponatremia with serum sodium concentration \<130 mmol/L, dextrose 5% will not be provided and MgSO4 will be administered in 50 mL of normal saline (NaCl 0.9%).

Intervention type: DRUG
Group type: EXPERIMENTAL
Intervention: Oral potassium supplements
Description: If serum potassium levels are \<3.5 mmol/L at any time during the administration of intravenous diuretics, oral potassium supplements are provided as needed to keep serum potassium levels \>4 mmol/L

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Intravenous hypertonic saline
Description: In case of hypotonic hyponatremia with serum sodium concentration \<125 mmol/L, a bolus of 150 mL hypertonic saline 3% is administered and repeated OD if necessary, until sodium levels are ≥135 mmol/L.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Switch to oral diuretic therapy
Description: Upon complete resolution of clinical signs of fluid overload with UNa \<80 mmol/L, intravenous diuretics are switched to an oral schedule including:~* Loop diuretics with dose \& frequency at the discretion of the treating physician~* Chlorthalidone 50 mg if added for diuretic resistance at any time during the intravenous diuretic phase~* Spironolactone 25 mg or another equivalent mineralocorticoid receptor antagonist

Intervention type: OTHER
Group type: ACTIVE_COMPARATOR
Intervention: Usual AHF care
Description: It is recommended to administer an intravenous loop diuretic dose at least BID (or through continuous infusion), with the aim of achieving a urine output 3-5 L per day until the patient is considered in an optimal volume status as is recommended by current guidelines.