Conditions: Acute Decompensated Heart Failure Volume Overload
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 519
Healthy volunteers: no

Brief summary:
This clinical research study is being conducted in multiple hospitals in Belgium and approximately 519 patients with acute decompensated heart failure are expected to participate. Large-scale research shows that 90% of the physicians treat volume overload with high doses of loop diuretics. However, there is not a lot of scientific data available regarding the optimal doses of these diuretic medications. In addition, it is observed that a lot of people, treated with these drugs, are being readmitted to the hospital due to a new episode of heart failure. The hypothesis of this study is that the volume overload could be better treated when patients receive a combination of different types of diuretics. Additionally, the total dose of the administrated diuretics might be lower this way.

Detailed description:
This is a randomized, double blind study with 2 treatment groups. This means that the patients will be randomized to one of the two treatment groups by chance. Patients randomized to the first group will receive standard treatment with high doses of intravenous loop diuretics and a placebo. Patients randomized to the other treatment group will receive a combination of the same doses of loop diuretics and an additional diuretic, acetazolamide (Diamox®). All diuretics will be administered intravenously. It is expected that the patients of the treatment group with the combination therapy will have a faster reduction of their fluid overload. In consequence the treatment duration and total dose of diuretics administered will be shorter. Acetazolamide (Diamox®) is a diuretic that acts at a different location in the kidney compared to the loop diuretics. This mutual reinforcement will probably reduce the total dose and duration of the diuretics.

The study will start during the hospitalization and will last around 3 months.

Arms:
arm 1: * At the moment of randomization (day 1), oral loop diuretics are stopped and the patient receives IV loop diuretics at a dose equal to the double of his oral daily maintenance dose + 500 mg IV bolus of placebo.
* If the patient still have signs of volume overload the next mornings (day 2 and day 3), the patient will receive IV loop diuretics at a dose equal to the oral daily maintenance dose + 500 mg IV bolus of placebo. It the patient has no sign of volume overload at these time points, the study treatment will be stopped. arm 2: * At the moment of randomization (day 1), oral loop diuretics are stopped and the patient receives IV loop diuretics at a dose equal to the double of his oral daily maintenance dose + 500 mg IV bolus of acetazolamide.
* If the patient still have signs of volume overload the next mornings (day 2 and day 3), the patient will receive IV loop diuretics at a dose equal to the oral daily maintenance dose + 500 mg IV bolus of acetazolamide. It the patient has no sign of volume overload at these time points, the study treatment will be stopped.

Interventions: intervention 1: Acetazolamide intervention 2: Placebo
Intervention descriptions: intervention 1: In the experimental group, the patient will receive the standard of care loop diuretics and acetazolamide intervention 2: In the placebo group, the patient will receive the standard of care loop diuretics and the placebo

Protocol document:
Prot_SAP_000.pdf: 
This supplement contains the following items: 
 
1. Study Protocol 
 
Original protocol: Version 1.0, dated May 9th, 2018. 
 
Final protocol: Version 2.0, dated January 3rd, 2019. 
 
Summary of all changes made between the first and final protocol (i.e. Final protocol 
– Appendix 6: Amendment history). 
 
2. Statistical Analysis Plan 
 
Original Statistical Analysis Plan: Version 1.0, dated January 17th, 2022. 
 
Final Statistical Analysis Plan: Version 2.0, dated March 17th, 2022 
 
Summary of all changes made between the first and final Statistical Analysis Plan (i.e. 
Final statistical analysis plan – section 1: Document history). 
 
3. Summary of Changes 
 
Between original (V1.0) and final (V2.0) protocol. 
 
Between original (V1.0) and final (V2.0) Statistical Analysis Plan.  
 
 


 
Original Protocol 
Version - 1.0 
9th of May 2018 
 


 
 
 
 
 
 
FULL/LONG TITLE OF THE TRIAL 
A multi-center, randomized, double-blind, phase IV clinical trial on the diuretic effects of Acetazolamide 
(Diamox ®) in patients with Decompensated heart failure and Volume OveRload 
SHORT STUDY TITLE / ACRONYM 
Acetazolamide (Diamox ®) in Decompensated heart failure with Volume OveRload (ADVOR) 
PROTOCOL VERSION NUMBER AND DATE 
Version number: version 1.0 
Version date: 09 May, 2018 
 
RESEARCH REFERENCE NUMBERS 
EudraCT Number: 
2018-001345-14 
Clinical trials.gov 
Number: 
NCT03505788 
SPONSOR Number: 
ZOLCAR17001 
KCE Trial Number: 
KCE-17001  


 
 
 
 
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 TABLE OF CONTENTS 
1 
BACKGROUND ................................................................................................................. 16 
2 
RATIONALE ...................................................................................................................... 17 
2.1 
ASSESSMENT AND MANAGEMENT OF RISK.................................................................................. 18 
3 
OBJECTIVES AND ENDPOINTS / OUTCOME MEASURES ............................................. 20 
3.1 
PRIMARY OBJECTIVE ........................................................................................................................ 20 
3.2 
SECONDARY OBJECTIVES ............................................................................................................... 20 
3.3 
ENDPOINTS ........................................................................................................................................ 20 
3.4 
PRIMARY ENDPOINT ......................................................................................................................... 21 
3.5 
SECONDARY ENDPOINTS ................................................................................................................ 21 
3.6 
EXPLORATORY TERTIARY ENDPOINTS ......................................................................................... 22 
4 
TRIAL DESIGN .................................................................................................................. 23 
5 
STUDY SETTING ............................................................................................................... 24 
6 
ELIGIBILITY CRITERIA ..................................................................................................... 25 
6.1 
INCLUSION CRITERIA ........................................................................................................................ 25 
6.2 
EXCLUSION CRITERIA ....................................................................................................................... 25 
7 
TRIAL PROCEDURES ....................................................................................................... 27 
7.1 
RECRUITMENT ................................................................................................................................... 27 
7.1.1 
Patient identification ............................................................................................................... 27 
7.1.2 
Screening ............................................................................................................................... 27 
7.2 
CONSENT ............................................................................................................................................ 28 
7.3 
THE RANDOMISATION SCHEME ...................................................................................................... 29 
7.4 
BLINDING ............................................................................................................................................ 29 
7.5 
UNBLINDING ....................................................................................................................................... 29 
7.6 
SCREENING PHASE ASSESSMENTS .............................................................................................. 30 
7.7 
TREATMENT PHASE ASSESSMENTS .............................................................................................. 31 
7.7.1 
Day 1 ...................................................................................................................................... 31 
7.7.2 
Day 2, Day 3 and Day 4 ......................................................................................................... 31 
7.8 
FOLLOW-UP PHASE ASSESSMENTS .............................................................................................. 32 
7.9 
TABLE OF TRIAL PROCEDURES ...................................................................................................... 33 
7.10 
LABORATORY SUB-STUDY ............................................................................................................... 34 
7.11 
WITHDRAWAL CRITERIA ................................................................................................................... 35 
7.12 
END OF TRIAL .................................................................................................................................... 35 
8 
TRIAL INTERVENTION / MEDICATION ............................................................................ 36 
8.1 
NAME AND DESCRIPTION OF INTERVENTION(S) .......................................................................... 36 
8.2 
LEGAL STATUS OF THE INTERVENTION ........................................................................................ 40 
8.3 
SUMMARY OF PRODUCT CHARACTERISTICS (SMPC) ................................................................. 40 
8.4 
DRUG STORAGE AND SUPPLY ........................................................................................................ 40 
8.5 
PREPARATION AND LABELLING OF INVESTIGATIONAL MEDICINAL PRODUCT ....................... 40 
8.6 
DOSAGE SCHEDULES ....................................................................................................................... 41 
8.7 
DOSAGE MODIFICATIONS ................................................................................................................ 41 
8.8 
ASSESSMENT OF COMPLIANCE ...................................................................................................... 41 
9 
SAFETY REPORTING ....................................................................................................... 42 
9.1 
DEFINITIONS ...................................................................................................................................... 42 


 
 
 
 
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9.2 
RECORDING AND REPORTING SAFETY INFORMATION ............................................................... 42 
9.3 
RESPONSIBILITIES ............................................................................................................................ 47 
9.4 
NOTIFICATION OF DEATHS .............................................................................................................. 48 
9.5 
REPORTING URGENT SAFETY MEASURES ................................................................................... 48 
9.6 
THE TYPE AND DURATION OF THE FOLLOW-UP OF SUBJECTS AFTER ADVERSE EVENTS .. 48 
9.7 
DEVELOPMENT SAFETY UPDATE REPORTS ................................................................................. 48 
10 
STATISTICS AND DATA ANALYSIS ................................................................................ 49 
10.1 
SAMPLE SIZE CALCULATION ........................................................................................................... 49 
10.2 
PLANNED RECRUITMENT RATE ...................................................................................................... 49 
10.3 
STATISTICAL ANALYSIS PLAN ......................................................................................................... 50 
10.4 
DATA COLLECTION FOR ECONOMIC EVALUATION ...................................................................... 51 
11 
DATA HANDLING .............................................................................................................. 54 
11.1 
DATA COLLECTION TOOLS AND SOURCE DOCUMENT IDENTIFICATION ................................. 54 
11.2 
DATA HANDLING AND RECORD KEEPING ...................................................................................... 55 
11.3 
ACCESS TO DATA .............................................................................................................................. 55 
11.4 
ARCHIVING ......................................................................................................................................... 55 
12 
MONITORING, AUDIT & INSPECTION ............................................................................. 56 
13 
ETHICAL AND REGULATORY CONSIDERATIONS ......................................................... 57 
13.1 
ETHICS COMMITTEE (EC) REVIEW & REPORTS ............................................................................ 57 
13.2 
PEER REVIEW .................................................................................................................................... 57 
13.3 
PUBLIC AND PATIENT INVOLVEMENT ............................................................................................ 57 
13.4 
REGULATORY COMPLIANCE............................................................................................................ 58 
13.5 
PROTOCOL COMPLIANCE ................................................................................................................ 58 
13.6 
NOTIFICATION OF SERIOUS BREACHES TO GCP AND/OR THE PROTOCOL ............................ 59 
13.7 
DATA PROTECTION AND PATIENT CONFIDENTIALITY ................................................................. 59 
13.8 
FINANCIAL AND OTHER COMPETING INTERESTS FOR THE CHIEF INVESTIGATOR, PIS AT 
EACH SITE AND COMMITTEE MEMBERS FOR THE OVERALL TRIAL MANAGEMENT ............... 60 
13.9 
INDEMNITY.......................................................................................................................................... 60 
13.10 
ACCESS TO THE FINAL TRIAL DATASET ........................................................................................ 60 
14 
DISSEMINATION POLICY ................................................................................................. 61 
14.1 
DISSEMINATION POLICY ................................................................................................................... 61 
14.2 
AUTHORSHIP ELIGIBILITY GUIDELINES AND ANY INTENDED USE OF PROFESSIONAL 
WRITERS ............................................................................................................................................. 62 
15 
REFERENCES ................................................................................................................... 64 
16 
APPENDIX 1: AUTHORISATION OF PARTICIPATING SITES ......................................... 67 
17 
APPENIX 2: EQ-5D QUESTIONNAIRE (DUTCH) .............................................................. 69 
18 
APPENDIX 3 : EQ-5D QUESTIONNAIRE (FRENCH) ........................................................ 71 
19 
APPENDIX 4 : URINARY COLLECTION PROCEDURE ................................................... 73 
20 
APPENDIX 5 : AMENDEMENT HISTORY ......................................................................... 74 
 








 
 
 
 
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Hasselt University 
Center for Statistics 
Agoralaan building D 
3590 - Diepenbeek 
Data Manager 
Liesbet Van Brussel 
Clinical Trial Unit, Ziekenhuis Oost-Limburg, Autonome Verzorgingsinstelling 
Schiepse Bos 6, 3600 Genk, Belgium 
E-mail: 
 
Phone: 
 
Committees 
Trial Steering Committee 
Trial Management Group 
Endpoint Adjudication Committee  
See below for more information regarding these committees  
 
 
 
 


 
 
 
 
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TRIAL SUMMARY 
Trail Title  
A multi-center, randomized, double-blind, phase IV clinical trial on the 
diuretic effects of Acetazolamide (Diamox ®) in patients with 
Decompensated heart failure and Volume OveRload 
Short title 
Acetazolamide (Diamox ®) in Decompensated heart failure with 
Volume OveRload 
Clinical Phase 
IV 
Study type 
Interventional 
Planned sample size 
Approximately 519 patient  
Trial duration 
Approximately 27 months (3 months follow-up / patient) 
Planned Trial Period 
2018-2021 
Purpose and rationale 
To investigate if combination therapy with acetazolamide improves loop 
diuretic efficacy to increase diuresis in decompensated heart failure 
(HF) patients, allowing for a better/faster decongestion and potentially 
resulting in improved clinical outcome and increased quality of life. 
Primary endpoint 
Treatment success (decongestion achieved) on the morning of day 4 
without the need for escalating diuretic strategy (doubling loop diuretic 
dose, addition of chlorthalidone, or ultrafiltration) on the morning of day 
3  
Secondary endpoints 
1. Combined end-point of all-cause mortality and heart failure 
readmission during 3 months of follow-up 
2. Length of index hospital admission 
3. Longitudinal 
changes 
in 
EuroQoL 
five 
dimensions 
questionnaire (EQ-5D) (baseline, the morning of day 4, any 
readmission, and 3 months). 
Trial Design 
The ADVOR study is a phase IV randomized, multi-center, double-blind 
study, comparing monotherapy with high-dose loop diuretics (standard 
of care - SOC) versus combination therapy with acetazolamide and 
high-dose loop diuretics in patients with decompensated heart failure 
and clinical signs of volume overload.  
The study consists of 3 phases: 
 
screening phase: starting from identifying a study subject prior 
to / during hospitalization until the first dose of study medication 
will be given 
 
treatment phase: starting from the first dose of study 
medication administration until the morning of day 4 or earlier 
in case of successful decongestion sooner. 
 
follow-up phase: starting when the treatment phase ends until 3 
months after the study start dose. 
Trial Participants 
The study population will consist of patients hospitalized with 
decompensated HF and demonstrating at least one clinical sign of 
volume overload. 
Main Inclusion Criteria 
 
An elective or emergency hospital admission with clinical diagnosis 
of ADHF and at least one clinical sign of volume overload (e.g. 
oedema, ascites or pleural effusion) 
 Maintenance therapy with oral loop diuretics at a dose of at least 
1 mg bumetanide or 40 mg furosemide or 20 mg torsemide for at 
least 1 month before hospital admission  
 Plasma NT-proBNP levels >1000 ng/mL or BNP levels >250 ng/mL 
at screening 
 


 
 
 
 
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Main Exclusion Criteria 
 
Concurrent diagnosis of an acute coronary syndrome defined as 
typical chest pain in addition to a troponin rise above the 99th 
percentile and/or electrocardiographic changes suggestive of 
cardiac ischemia 
 A previous or current diagnosis of hypertrophic, restrictive, or 
constrictive cardiomyopathy as documented in the medical record 
 History of congenital heart disease requiring surgical correction 
 History of cardiac transplantation and/or ventricular assist device 
 Systolic blood pressure <90 mmHg or mean arterial pressure 
<65 mmHg at the moment of admission 
 Expected 
use 
of 
intravenous 
inotropes, 
vasopressors 
or 
nitroprusside during the study. Use of nitrates is allowed only if the 
patient’s systolic blood pressure is >140 mmHg 
 Estimated glomerular filtration rate (eGFR) <20 mL/min/1.73m² at  
screening 
 Use of renal replacement therapy or ultrafiltration at any time before 
study inclusion 
 Treatment with intravenous loop diuretics > 2 mg bumetanide or an 
equivalence of another loop diuretic during the index hospitalization 
before randomization 
 Treatment with acetazolamide during the index hospitalization 
before randomization 
 Exposure to nephrotoxic agents (i.e. contrast dye) anticipated within 
the next 3 days 
 Use of any non-protocol defined diuretic agent with the exception of 
mineralocorticoid receptor antagonists. Thiazides, metolazone, 
indapamide and amiloride should be stopped upon study inclusion. 
If patient is taking a combination drug including a thiazide-type 
diuretic, the thiazide-type diuretic should be stopped upon study 
inclusion. 
 Current use of sodium-glucose transporter-2 inhibitors 
 Subjects who are pregnant or breastfeeding  
Exploratory tertiary end-
points 
 Body weight change after day 1, 2, 3, 4 and discharge compared to 
admission 
 All-cause mortality during first 3 months after study start dose 
 Heart failure readmissions during first 3 months after study start 
dose 
 All cause rehospitalisation during first 3 months. after study start 
dose 
 Total urinary volume and natriuresis starting from first intravenous 
(IV) diuretic administration at randomization until the morning of day 
3 (urinary output, see figure 1 and appendix 4) 
 Relative plasma BNP or NT-proBNP change from baseline until the 
assessment of the secondary endpoint on day 4 and at 3 months 
 Total dose of IV loop diuretics used during first 4 days 
 Changes in doses of neurohumoral blockers from baseline to 
discharge and after 3 months. 
 Need for renal replacement therapy or ultrafiltration during first 3 
months after study start dose 
 Incidence of hyponatremia during treatment phase 
 Hypokalaemia during treatment phase 
 Incidence of metabolic acidosis requiring NaHCO3 supplements 
during first 4 days 
 WRF defined as a >0.3 mg/dL increase in serum Cr, or a >20% 
decrease in eGFR by the CKD-EPI formula during treatment phase 
 Liver dysfunction on admission 
 plasma volume changes during treatment phase (assessed by 


 
 
 
 
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albumin and hematocrit) 
 Occurrence of iron deficiency on admission 
Optional laboratory sub-study in participating centers: 
 Change from baseline in selected biomarkers from baseline through 
3 months after study start dose in a subset of randomized patients 
Safety assessments 
 
Adverse events 
 
Laboratory values (including monitoring hypokalaemia, metabolic 
acidosis, substantial increase in creatinine (Cr), substantial 
decrease in eGFR) 
Data analysis 
 
The treatment effect for the primary end-point is evaluated by 
means of a generalized linear mixed model. The statistical model 
will include a fixed treatment effect and random center effect. 
 
For the first secondary end-point [occurrence of the combined 
endpoint of all-cause mortality and heart failure re-admission during 
3 months of follow-up], a generalized linear mixed model for a 
binary outcome will be used.  The model will incorporate a fixed 
treatment effect and random center effect.  If the treatment effect 
on the composite endpoint of ‘all-cause mortality and HF 
readmission’ turns out to be statistically significant, both 
components will be evaluated separately in a hierarchical fashion 
with HF readmissions first and all-cause mortality second. 
 
Length of index hospitalization and change in quality of life scores 
are compared among treatment arms with a linear mixed model 
(fixed treatment effect and random center effect). Transformation 
will be employed when the model assumptions (such normality) are 
violated.  
 
All hypothesis are 2-sided and tested with a significance level of  
α=0.05 
 
 
 
 
 


 
 
 
 
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ROLE OF STUDY SPONSOR AND FUNDER 
Ziekenhuis Oost Limburg autonome verzorginsinstelling (ZOL AV), as mentioned in KEY TRIAL 
CONTACT shall act as sponsor of the Study, as defined in the Law of 2004, and in accordance with the 
Law of 2004, the sponsor shall assume, even without fault, the responsibility of any damage incurred by a 
study patient or, in the case of death, his rightful claimants sustained that arises either in direct or indirect 
connection with the experiments and shall provide compensation therefore. The Sponsor shall enter into 
an insurance contract in accordance with article 29 of the Law of 2004.  ZOL AV shall ensure that it shall 
be mentioned in the Protocol, the Informed Consent Forms and in other relevant communication with the 
Study Subjects or the Regulatory Authorities as sponsor of the Study.  
ZOL AV has designed the trial together with the aforementioned Study steering committee. ZOL AV and 
the steering committee will be responsible for the data analysis (with assistance of the “center of 
statistics”, University Hasselt), interpretation, manuscript writing, and dissemination of results. ZOL AV 
will have the final decision regarding any of these aspects of the trial. However, publication of the main 
study results will be the responsibility of the steering committee. Even in case of a negative study result, 
the data will be published. 
ZOL AV acknowledges and agrees for the avoidance of doubt that KCE shall under no circumstances be 
considered as sponsor of the Study or assume any responsibilities or liabilities in connection therewith, 
and ZOL AV shall make no representations whatsoever in this respect.  
 
 


 
 
 
 
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ROLES AND RESPONSIBILITIES OF TRIAL MANAGEMENT 
COMMITEES 
Trial Steering Committee (TSC) 
The role of the Trial Steering Committee (TSC) is to provide the overall supervision of the trial. The TSC 
includes members who are independent of the investigators, their employing organisations or institutions, 
funders and sponsors. The TSC monitors trial progress, conduct and advise on scientific credibility. The 
TSC will consider and act, as appropriate, and ultimately carries the responsibility for deciding whether a 
trial needs to be stopped on grounds of safety or efficacy. The TSC shall oversee the performance of the 
study and discuss important topics in relation thereto.  
The TSC will meet on average 3 times per year or as necessary when adapted to the stage of the trial 
(set-up, conduct, analysis). The TSC is composed of the CI, trial statistician, the trial PM, 7 independent 
experts, minimum 2 representatives of other participating centers with at least one representative of the 
French speaking sites and one representative of the Dutch speaking sites, up to 2 representatives of 
patients or the general public, 1 representative of the sponsor and 1 representative of the funder. The 
TSC will send reports to the sponsor and the funder. KCE shall have the right (but not the obligation) to 
be present at each TSC meeting. 
Details of the final members of the TSC, their responsibilities, number of meetings and reporting 
procedures can be found in the TSC charter.  
Trial Management Group (TMG) 
The TMG includes those individuals responsible for the day-to-day management of the trial, such as the 
Chief Investigator, statistician, trial manager, and data manager. The role of the group is to monitor all 
aspects of the conduct and progress of the trial, ensure that the protocol is adhered to and take 
appropriate action to safeguard participants and the quality of the trial itself.  
Chief Investigator: Wilfried Mullens (ZOL AV, Genk, Belgium) 
Statistician: Liesbeth Bruckers (University Hasselt, Belgium)    
Trial Manager: Katrien Tartaglia (ZOL AV, Genk, Belgium)   
Data Manager: Liesbet Van Brussel (ZOL AV, Genk, Belgium)   
Data Safety Monitoring Committee (DSMC)  
The DSMC is not needed as this is a low-risk pragmatic interventional trial with a short inclusion period 
studying an old drug with a well-known safety profile within an accepted clinical indication. 
Endpoint Adjudication Committee (EAC)  
The EAC will adjudicate the HF-related endpoints. The EAC will meet at regular intervals throughout the 
course of the study to assess events, and determine whether these events should contribute to the 
secondary endpoints of the ADVOR trial. HF readmissions are defined as either a hospital admission 
because of decompensated HF or an unscheduled contact at the emergency department for worsening 


 
 
 
 
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HF if the patient is treated with intravenous loop diuretics. The EAC will have at least two members, 
specializing in heart failure management. None of the EAC members will be participating investigators in 
the ADVOR trial. 
LIST OF ABBREVIATIONS 
 
 
ADHF 
Acute Decompensated Heart Failure 
AE 
Adverse Event 
BID 
“Bis in die” (twice a day) 
BWGHF 
Belgian Working Group of Heart Failure 
BNP 
B-type natriuretic peptide 
CI 
Chief Investigator 
Cr 
Creatinine 
EAC 
Endpoint Adjudication Committee 
eCRF 
Electronic Case Report Form 
EF 
Ejection fraction 
eGFR 
Estimated glomerular filtration rate  
EQ-5D 
EuroQol five dimension (questionnaire) 
ESC 
European society of Cardiology 
GCP 
Good Clinical Practice 
GMP 
Good Manufacture Practice 
HFA 
Heart Failure Association 
HF 
Heart Failure 
HFpEF 
Heart Failure with preserved Ejection Fraction 
HFrEF 
Heart Failure with reduced Ejection Fraction 
HTA 
Health technology assessment 
IEC 
Independent ethics committee 
IMP 
Investigational medicinal product 
IRT 
Interactive response technology 
ISF 
Investigator Site File 
IV 
Intravenous 
NT-proBNP 
N-terminal of pro-B-type natriuretic peptide 
MG 
milligram 
PI 
Principal Investigator 
PM 
Project Manager 
QoL 
Question of Life 
RCT 
Randomised Clinical Trial 
RRT 
Renal replacement therapy 
SD 
Source document 
SI 
Sub-investigator 
SOC 
Standard of care 
TMG 
Trial Management Group 


 
 
 
 
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TSC 
Trial Steering Committee 
VAS 
Visual analogue scale 
WRF 
Worsening renal function 
ZOL AV 
Ziekenhuis Oost Limburg Autonome Verzorgingsinstelling 
 
 
 


 
 
 
 
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TRIAL FLOW CHART 
Figure 1. Trial flow Chart. 
 


 
 
 
 
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1 BACKGROUND 
Aging of the population and prolongation of the lifespan of cardiac patients by modern therapeutic 
innovations have led to an increased incidence of HF (1). During the last two decades, important progress 
has been made in the treatment of ambulatory HFrEF patients. Renin-angiotensin system blockers, 
β-blockers, mineralocorticoid receptor antagonists, ivabradine, neprilysin inhibition, and cardiac 
resynchronization therapy have all been demonstrated to reduce morbidity and/or mortality in ambulatory 
HFrEF patients (2-18).  
Despite these important advances, many patients are still hospitalized frequently with decompensated HF 
demonstrating most often signs and symptoms of systemic congestion and volume overload, which is 
associated with worse outcome (19). Treatment in these cases mainly focuses on symptomatic relief 
through administration of diuretics, although clear evidence on the optimal agent, dosing schedule, and 
administration route is lacking. Coexisting renal dysfunction often complicates decongestive treatment 
and worsening renal function (WRF), often defined as a 0.3 mg/dL rise in serum Cr, is a common finding 
in this context (20). However, the prognostic impact of WRF defined as Cr change is unsure as it might be 
associated with worse, neutral or even better outcome (21-23). In contrast, persistent congestion and 
volume overload, as a reflection of the renal inability to preserve sodium homeostasis, has been more 
consistently associated with higher mortality and more frequent readmissions in HF (24). This suggests 
that achieving a net negative fluid balance might be an attractive treatment target in decompensated HF. 
Loop diuretics are by far the most commonly used agents to achieve decongestion in decompensated 
HF. Especially in diuretic-naïve patients, they are often very effective to relief dyspnoea and congestive 
symptoms. However, in the Diuretic Optimization Strategies Evaluation (DOSE) trial, which is the only 
randomized clinical trial on diuretic therapy for decompensated HF patients, no differences in patients’ 
global assessment of symptoms or change in renal function were observed when loop diuretics were 
administered by bolus as compared with continuous infusion or at high versus low dose during a 
hospitalization for decompensated HF (25). Also, only a minority of patients (15%) were adequately 
decongested after 72 h in the DOSE trial, thereby indicating the urgent need for more effective 
decongestive therapies. Furthermore, guidelines from international cardiac societies lack high-quality data 
on the optimal dosing, timing and method of delivery of diuretic agents. Importantly, there are several 
reasons why loop diuretics might be less effective or even harmful in HF. First, loop diuretics directly 
stimulate renin production by inhibiting the Na+/K+/2Cl--cotransporter on the luminal side of the macula 
densa, which depletes intracellular chloride levels in the macula densa. The consequence is an increased 
cyclo-oxygenase-2 and nitric oxide synthase I activity in macula densa cells, leading to paracrine 
prostaglandin E2 and nitric oxide secretion (26). Both prostaglandin E2 and nitric oxide work in concert to 
stimulate renin release by granulosa cells of the afferent arteriole and further detrimental activation of the 
renin-angiotensin-aldosterone axis. Second, impaired secretion of loop diuretics in the proximal tubules of 
HF patients, especially when there is concomitant renal dysfunction, results in lower concentrations at the 
place where these agents act – the luminal side of the thick ascending limb of Henle’s loop. Third, 
increased sodium reabsorption in the proximal tubules might result in less sodium offered to the thick 


 
 
 
 
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ascending limb of Henle’s loop, especially if glomerular filtration is concomitantly impaired, hampering the 
efficacy of loop diuretics. 
Recent advances in heart failure (HF) biomarker studies suggest promise from markers enhancing 
traditional method of assessing affected patients. B-type natriuretic peptide (BNP) and its biologically 
inert, amino-terminal pro-peptide counterpart (NT-proBNP)32,33 have quickly become an essential 
component in the diagnosis and determining prognosis in HF. With a large number of biomarkers now or 
soon to be available, an understanding of the role that biomarkers may play in HF care is necessary. 
2 RATIONALE  
From a pathophysiological point of view, targeting sodium reabsorption in the proximal tubules has 
several potential benefits in HF. First, it is the place where most sodium is reabsorbed, especially in 
decompensated HF. Second, greater delivery of chloride to macula densa cells decreases renin 
production, ceasing neurohumoral activation. Third, endogenous natriuretic peptides (acting in the distal 
nephron) will possibly regain their effects (27). The carbonic anhydrase inhibitor acetazolamide 
(Diamox®), which is approved for the treatment of mountain sickness, inhibits sodium reabsorption in the 
proximal tubules. Despite the pathophysiological rationale for inhibition of proximal sodium reabsorption in 
decompensated HF, acetazolamide is now a largely forgotten diuretic. One observational study in 
patients with decompensated HF and marked volume overload found that the addition of acetazolamide 
improved loop diuretic efficacy with ~100 mmol Na+ excreted per 40 mg of furosemide equivalent dose 
(28). Thus, although the diuretic and natriuretic capacity of acetazolamide is poor on its own, it might well 
be a very efficient booster of diuretic efficacy in combinational diuretic therapy with loop diuretics. This 
concept is further supported by one small randomized trial including 24 patients with volume overload 
refractory to loop diuretic therapy (29). All these patients demonstrated a greatly reduced fractional 
sodium excretion, which was easily overcome by the addition of acetazolamide. We’ve conducted a small 
two-center trial to see if improved diuretic efficacy with acetazolamide in a patient population with heart 
failure and cardio-renal syndrome at high risk for diuretic resistance translates into better natriuresis. 
(Clinical Trial NCT01973335). The study has just been finished with analysis of the results ongoing. 
Importantly, the promising concept of blocking proximal nephron sodium absorption with acetazolamide 
has been published over the last couple of years (30). 
The ADVOR study has an innovative primary end-point. As abundant evidence has consistently linked 
persistent volume overload after decongestive therapy in decompensated HF with poor outcomes, 
decongestion itself is a valid surrogate end-point (24). It has been demonstrated from reanalysis of the 
DOSE trial and CARRESS that the persistent oedema has excellent prognostic ability to predict death, 
readmissions or unscheduled medical contacts (31). In ADVOR, a more exhaustive congestion score with 
the emphasis on relief of volume overload will be used. Secondary end-points in ADVOR will be very 
clinically relevant. A more thorough decongestion should also translate into less readmissions for 
recurrent decompensation, better renal preservation, and eventually lower mortality. This will be assessed 
as a key secondary end-point after hospital stay. Additionally, time to decongestion is a major 
determinant of hospital stay and combinational therapy with acetazolamide might significantly shorten 


 
 
 
 
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this. Finally, improved quality of life for patients is expected with better decongestion and will be the last 
secondary end-point. Importantly, acetazolamide is an easy and cheap drug to use (add on, bolus 
infusion, no special monitoring required), with a potentially favourable cost-efficiency profile. Important 
health economic data, specifically for the Belgian situation, will be obtained through the ADVOR study.  
During the ADVOR study centers can decide to participate in the optional laboratory sub-study. The urine 
and blood samples collected through this laboratory sub-study will be stored in the University Biobank of 
Limburg and it will become the biggest databank of its kind within diuretic studies for patients with 
decompensated heart failure.  
This laboratory sub-study will investigate more in detail the mechanistic and potential favourable effect of 
acetazolamide and loop diuretics. Furthermore, this laboratory sub-study will provide new insights into the 
pathophysiology of decompensated HF and potentially will allow for identifying a high risk patient 
population. This could ultimately lead to improved and patient tailored treatment strategies. Biomarker 
sub-studies have become a valuable source of data fur such analysis, and offer unique insights in to 
mechanistic and pathophysiologic pathways in a well selected and phenotyped patient population.   
 
2.1 Assessment and management of risk 
The study will examine if the addition of acetazolamide will lead to a better decongestion in 
decompensated HF patients with volume overload. It’s expected the better decongestion will lead to less 
HF readmissions, reduced all-cause mortality, improved quality of life, reduced hospital stay duration and 
significant reduction in HF related health care expenditure.  
The ADVOR trial will investigate if adding acetazolamide, which can be very easily administered, in every 
hospital, without additional extra testing or invasive monitoring, through a bolus infusion in acute 
decompensated heart failure (ADHF) patients might lead to faster, safer and easier decongestion. If 
proven beneficial, this approach can easily be adopted by every hospital in a quick manner with 
considerable cost-savings with regards to health care expenditure and improvements of quality of life for 
patients. 
Importantly, ADVOR will examine if an improved application of existing decongestive therapies (not novel 
drugs), based on strong scientific reasoning, will result in a better outcome for patients and society. 
Therefore, data from the study will provide information regarding the safety and efficacy of acetazolamide 
treatment in above mentioned patient population.  
As such, the ADVOR study was specifically designed to have maximum benefit without additional risk for 
this frail patient population. The study will: 
1) Be conducted with limited additional testing 
2) Have minimal or no additional expected risk for the patient (comparison of standard diuretic 
regimen with standard diuretic regimen + addition of acetazolamide) 


 
 
 
 
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3) Have very clinically meaningful endpoints. Achieving a faster decongestion with reduced risk for 
escalation of therapy, which often increases complication rates as well as length of hospital stay. 
This will be beneficial for the patients in the short-term. Additionally, a more thorough 
decongestion should also translate into less readmissions for recurrent decompensation and 
improved quality of care 
Therefore, ADVOR can be considered a ‘Low-intervention clinical trial’ as: 
1) Acetazolamide, the investigational medicinal products, which already has been authorised, has a 
very low risk profile and is well-known to the general cardiologist 
2) According to the protocol of the clinical trial, Acetazolamide the investigational medicinal product, 
will be used in accordance with the terms of the marketing authorisation  
3) The additional diagnostic or monitoring procedures do not pose more than minimal additional risk 
or burden to the safety of the subjects compared to normal clinical practice 
 


 
 
 
 
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3 
OBJECTIVES AND ENDPOINTS / OUTCOME MEASURES  
ADVOR will investigate if combination therapy with acetazolamide improves loop diuretic efficacy to 
increase diuresis in decompensated HF patients with volume overload, allowing for a better/faster 
decongestion and a lower total dose of loop diuretics. A better / faster decongestion should lead to less 
HF readmission, reduced all-cause mortality, shorter length of stay and improved quality of life. 
3.1 Primary objective 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy 
with high-dose loop diuretics (standard of care - SOC) versus combination therapy with acetazolamide 
and high-dose loop diuretics in patients with decompensated HF and clinical signs of volume overload. 
While the SOC results in 15% effective decongestion, it’s estimated - based on strong scientific reasons - 
that the combination therapy should have a success rate of 25%, which represents a clear meaningful 
benefit of 10% more patients with appropriate decongestion after 72 h.  
- 
Population; patients hospitalized with decompensated HF and demonstrating signs of volume 
overload. 
- 
Intervention: combination therapy with high-dose loop diuretics + acetazolamide 
- 
Comparison: monotherapy with high-dose loop diuretics + placebo 
- 
Outcome: % decongestion, need for escalating diuretic therapy, HF readmission, all-cause mortality, 
length of stay, QoL 
- 
Time: 72 h for primary endpoint, 3 months for secondary endpoint 
3.2 Secondary objectives 
1. Combination therapy with acetazolamide improves loop diuretic efficacy to increase diuresis in 
decompensated HF patients, allowing for a better/faster decongestion and a lower total dose of 
loop diuretics. 
2. Combination therapy with acetazolamide leads to lower occurrence of diuretic resistance and 
escalating diuretic therapy in decompensated HF 
3. Combination therapy with acetazolamide will potentially lead to improved clinical outcome in 
decompensated HF (less heart failure readmissions, lower all-cause mortality)  
4. Combination therapy with acetazolamide will shorten the length of stay in patients with 
decompensated HF, which is expected to reduce health care expenditure 
5. Combination therapy with acetazolamide will potentially lead to improved quality of life 
3.3 Endpoints  
The ADVOR study has an innovative primary end-point. As abundant evidence has consistently linked 
persistent volume overload after decongestive therapy in decompensated HF with poor outcomes, 
decongestion itself is a valid surrogate end-point. It has been demonstrated from reanalysis of the DOSE 
trial and CARRESS that the persistent oedema has excellent prognostic ability to predict death, 


 
 
 
 
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readmissions or unscheduled medical contacts. In ADVOR, a more exhaustive yet easy to use – ‘volume 
assessment’ score - will be used. Importantly, ADVOR will be a double blind randomized trial thereby 
excluding any potential for bias in the clinical judgement of the treating physician for any of the endpoints 
including the primary endpoint of decongestion.  
Secondary endpoints in ADVOR will be very clinically relevant. A more thorough decongestion should 
also translate into less readmissions for recurrent decompensation, and eventually lower mortality. This 
will be assessed as a key secondary end-point after hospital stay. Additionally, time to decongestion is a 
major determinant of hospital stay and combinational therapy with acetazolamide might significantly 
shorten this. Finally, improved quality of life for patients is expected with better decongestion and will be 
the last secondary endpoint. Importantly, acetazolamide is an easy drug and very cheap drug to use (add 
on, bolus infusion, no special monitoring required), which will therefore be easily adopted by the health 
care. Endpoints have also been discussed with “Mon Coeur Entre Parenthèses” which is a HF patient 
association (VZW) representing HF patients and their peers and deemed to be important by them. 
In addition, the primary and secondary outcome measures are in line with the COMET (Core Outcome 
Measures in Effectiveness Trials) initiative. Indeed ‘decongestion’ (being dry is for the patient a very 
important improvement in symptomatology), heart failure readmission, all-cause mortality, length of stay, 
quality of life….can all be considered standardised relevant core outcomes sets. Therefore, the core 
outcomes relevant for any acute heart failure study will be collected and reported, making it easier for the 
results of ADVOR to be compared, contrasted and combined as appropriate with other trials (Zannad F et 
al, European Journal of Heart Failure, 2013;15:1082-1094). Additionally, we will continue to explore other 
tertiary outcomes, which are often mechanistically very interesting, as well. 
We will also collect the dosages of neurohumoral blocker therapy throughout the study period, thereby 
hopefully facilitating a better implementation of guideline recommended therapy. As guidelines 
recommend a specific dosage for each of these drugs in HFrEF, it’s easy to standardize the intake of 
such medications to be used in an accurate analysis. This will be done as an exploratory tertiary end-
point. 
3.4 Primary endpoint 
Treatment success (decongestion achieved) on the morning of day 4 without the need for escalating 
diuretic strategy (doubling loop diuretic dose, addition of chlorthalidone, or ultrafiltration) on the morning 
of day 3.  
3.5 Secondary endpoints  
1. Combined end-point of all-cause mortality and heart failure readmission during 3 months of 
follow-up 
2. Length of index hospital admission 
3. Longitudinal changes in EuroQoL five dimensions questionnaire (EQ-5D) (baseline, the morning 
of day 4, at any readmission, 3 months) 


 
 
 
 
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3.6 Exploratory tertiary endpoints   
1. Body weight change after day 1, 2, 3, 4 discharge compared to admission   
2. All-cause mortality during first 3 months after study start dose 
3. Heart failure readmissions during first 3 months after study start dose 
4. All cause rehospitalisation during first 3 months after study start dose 
5. Total urinary volume and natriuresis starting from first intravenous (IV) diuretic administration at 
randomization until the morning of day 3  
6. Relative plasma BNP or NT-proBNP change from baseline until day 4 and at 3 months follow up 
visit 
7. Total dose of IV loop diuretics used during first 4 days 
8. Changes in doses of neurohumoral blockers from baseline to discharge and after 3 months. 
9. Need for renal replacement therapy or ultrafiltration during first 3 months after study start dose 
10. Hyponatremia during treatment phase 
11. Hypokalaemia during treatment phase 
12. Incidence of metabolic acidosis requiring NaHCO3 supplements during first 4 days 
13. WRF defined as a >0.3 mg/dL increase in serum Cr, or a >20% decrease in eGFR by the CKD-
EPI formula during treatment phase 
14. Liver dysfunction on admission 
15. plasma volume changes during treatment phase (assessed by albumin and hematocrit) 
16. Occurrence of iron deficiency on admission 
17. Optional laboratory sub-study in participating centers: Change from baseline in selected 
biomarkers from baseline through 3 months after study start dose in a subset of randomized 
patients 
 
 


 
 
 
 
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4 TRIAL DESIGN 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy of 
high-dose loop diuretics (SOC) versus combination therapy of acetazolamide with high-dose loop 
diuretics in patients with decompensated HF and volume overload. Data from the study will provide 
information regarding the safety and efficacy of acetazolamide treatment in the above-mentioned patient 
population. Randomized clinical trial with 2 treatment arms; therapy with high-dose loop diuretics and 
placebo vs therapy with high-dose loop diuretics and acetazolamide. An automated web-based system is 
used to randomly assign patients in a 1:1 ratio with variable blocks sizes, stratified for LVEF according to 
study center. To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the 
population will be stratified at inclusion according to LVEF ≤40% versus >40%. Permuted block 
randomisation, at center and LVEF stratum level will be used to achieve this. Objective is to demonstrate 
superiority of the combination therapy with regards to achieving decongestion at 72 hours.  
The study consists of 3 phases (cfr Figure 1 Flow Chart): 
 
screening phase: starting from identifying a study subject prior / during hospitalization until the 
first dose of study medication will be given  
 
treatment phase: starting from the first dose of study medication administration until the morning 
of day 4 or earlier in case of successful decongestion sooner 
 
follow up phase: starting when the treatment phase ends until 3 months after the study start dose 
 
 


 
 
 
 
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5 STUDY SETTING 
The study population will consist of patients hospitalized for decompensated HF with clinical signs of 
volume overload. The goal is to randomize approximately 519 patients in approximately 24 centers in 
Belgium. Importantly, participating centers are located in Flanders, Wallonia and Brussels, which also 
ensures that the study population is representative of the real-life patient population in which the study 
drug will be used in case the study is positive.  
The study will be supported by the members of the Belgian Working Group of Heart Failure (BWGHF). 
This is a national scientific non-profit group which was established in 2004 as one of the official working 
groups of the Belgian Society of Cardiology. Therefore, a positive result will almost immediately be 
adopted by the Belgian cardiology community as all members of the BWGHF are considered leaders in 
the field.  
Finally, only centers who have fulfilled all the duties with regards to study selection and training will be 
allowed to randomize patients. 
 
 


 
 
 
 
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6 ELIGIBILITY CRITERIA 
Decompensated HF patients with volume overload independent of ejection fraction might be included. 
This is important as 50% of decompensated HF patients are HFpEF patients (HF with preserved ejection 
fraction) and 50% of the decompensated HF patients are HFrEF patients (HF with reduced ejection 
fraction). In addition, patients do not need to have an echocardiogram at study inclusion to establish left 
ventricular ejection fraction which further simplifies the inclusion procedure. Finally, the DOSE trial (only 
other RCT studying the effects of diuretic therapy) also included patients without pre-specification of EF. 
To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the population will be 
stratified at inclusion according to LVEF ≤40% versus >40% (assessed within 12 months before 
inclusion). Permuted block randomisation according to center and LVEF stratum will be used to achieve 
this.  
Importantly, though the diagnosis of HF sometimes is difficult to establish in HFpEF, the main inclusion 
criteria are; 1) clinical diagnosis of decompensated HF and at least one clinical sign of volume overload 
(e.g. oedema, ascites or pleural effusion), 2) increased BNP / NT-ProBNP to ensure the volume overload 
is secondary to congestion/heart failure and 3) maintenance therapy with oral loop diuretics at a dose of ≥ 
1 mg bumetanide or equivalent dose for ≥ 1 month before hospital admission will be remained. The 
combination of these three criteria will guarantee that only decompensated HF patients with volume 
overload will be included.  
6.1 Inclusion criteria 
 
Signed written informed consent must be obtained before any study assessment is performed 
 
Male or female patients 18 years of age or older 
 
An elective or emergency hospital admission with clinical diagnosis of decompensated HF with at 
least one clinical sign of volume overload (e.g. oedema (score 2 or more), ascites confirmed by 
echography or pleural effusion confirmed by chest X-ray or echography) 
 
Maintenance therapy with oral loop diuretics at a dose of at least 1 mg bumetanide or an 
equivalent dose for at least 1 month before hospital admission (Conversion: 1 mg bumetanide = 
40 mg furosemide = 20 mg torsemide) 
 
Plasma NT-proBNP levels >1000 ng/mL or BNP levels >250 ng/mL at the time of screening. 
 
Assessed LVEF by any imaging technique; i.e. echocardiography, catheterization, nuclear scan 
or magnetic resonance imaging within 12 months of inclusion 
6.2 Exclusion criteria 
 
Concurrent diagnosis of an acute coronary syndrome defined as typical chest pain in addition to a 
troponin rise above the 99th percentile and/or electrocardiographic changes suggestive of cardiac 
ischemia 
 
History of congenital heart disease requiring surgical correction 
 
History of a cardiac transplantation and/or ventricular assist device 


 
 
 
 
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 
Systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg at the moment of 
admission 
 
Expected use of intravenous inotropes, vasopressors or nitroprusside during the study. Use of 
nitrates is allowed only if the patient’s systolic blood pressure is >140 mmHg 
 
Estimated glomerular filtration rate <20 mL/min/1.73m² at screening 
 
Use of renal replacement therapy or ultrafiltration at any time before study inclusion 
 
Treatment with intravenous loop diuretics > 2 mg bumetanide or an equivalence of another loop 
diuretic during the index hospitalization and prior to randomization 
 
Treatment with acetazolamide during the index hospitalization and prior to randomization 
 
Exposure to nephrotoxic agents (i.e. contrast dye) anticipated within the next 3 days 
 
Use of any non-protocol defined diuretic agent with the exception of mineralocorticoid receptor 
antagonists. Thiazides, metolazone, indapamide and amiloride should be stopped upon study 
inclusion. If patient is taking a combination drug including a thiazide-type diuretic, the thiazide-
type diuretic should be stopped 
 
Current use of sodium-glucose transporter-2 inhibitors 
 
Subjects who are pregnant or breastfeeding  
 
 


 
 
 
 
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7 TRIAL PROCEDURES  
7.1 Recruitment 
Patients might be enrolled during an admission of decompensated HF with volume overload, on the 
condition of fulfilling inclusion and not fulfilling exclusion criteria. In addition, patients might already be 
informed that they could participate in study during an outpatient visit (if they need to be hospitalized for 
decompensated HF). Patients will be recruited by the sites within a period of approximately 24 months.  
7.1.1 Patient identification 
It is recommended to inform the medical team (cardiology and the health care providers) who might have 
first contact with potential study subjects (e.g. emergency room physicians) about the trial. They should 
inform the subject regarding the trial. Only a member of the patient’s existing clinical care team should 
have access to patients’ records without explicit consent in order to identify potential participants and 
check whether they meet the inclusion criteria or make the initial approach to patients. In case the treating 
physician is not a member of the ADVOR trial (a principal investigator (PI) or sub-investigator (SI)), 
he/she could refer the patient to the ADVOR investigator. The screening process can start only if a written 
informed consent is obtained. The investigator of the ADVOR trial should confirm eligibility of the subject. 
Potential participants might also be recruited through publicity (posters, leaflets) which can be made 
publically available in cardiology outpatient departments only if approval has been obtained by the ethics 
committee. 
7.1.2 Screening 
Following screening technical requirements are necessary to meet any noted inclusion or exclusion 
criteria: 
 
laboratory tests (BNP or NT-proBNP part of inclusion criteria and eGFR part of exclusion 
criteria) 
 
chest X ray or chest ultrasound in case pleural effusion is used as inclusion criteria. Importantly, 
a chest X-ray is considered standard of care in case of decompensated HF (guidelines of the 
European Society of Cardiology (ESC))  
 
abdominal ultrasound in case ascites is used as inclusion criteria 
No other technical procedure needs to performed as part of routine care. However, the LVEF assessed 
by any technical exam (echocardiogram, nuclear scan, MRI, catheterization) within the last 12 months will 
need to be recorded. As only patients already treated with a loop diuretic are allowed in the study, we 
expect that every patient has a LVEF recorded within 12 months preceding study entry.  
We don’t expect screen failures i.e. patients who do not meet eligibility criteria at time of screening to be 
able to enter the study at a later stage as we expect them to have received already more than 2 mg loop 
diuretics intravenously (which will count as an exclusion criterium). 


 
 
 
 
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Patients will not receive any special incentives or compensation through participation in the study. No 
specific study visits are needed. The 3 month FU visit is standard of care as recommended by the 
guidelines of the ESC. Study related exams (BNP or NT-proBNP) will be reimbursed by the study. 
7.2 Consent  
The Principal Investigator (PI) retains overall responsibility for the informed consent of participants at their 
site and must ensure that any person delegated responsibility to participate in the informed consent 
process is duly authorised, trained and competent to participate according to the ethically approved 
protocol, principles of Good Clinical Practice (GCP) and Declaration of Helsinki. If delegation of consent is 
acceptable then details should be provided. 
Informed consent must be obtained prior to the participant undergoing procedures that are specifically for 
the purposes of the trial and are outside of standard routine care at the participating site (including the 
collection of identifiable participant). In case the patient agrees to participate in the optional laboratory 
sub-study, an additional signed and dated informed consent must be obtained before the laboratory sub-
study blood and urine samples will be collected.  
The right of a participant to refuse participation without giving reasons must be respected.   
The participant must remain free to withdraw at any time from the trial without giving reasons and without 
prejudicing his/her further treatment and will be provided with a contact point where he/she may obtain 
further information about the trial. Where a participant is required to re-consent or new information is 
required to be provided to a participant it is the responsibility of the PI to ensure this is done in a timely 
manner.  
The PI takes responsibility for ensuring that all vulnerable patients are protected and participate 
voluntarily in an environment free from coercion or undue influence. 
Eligible patients may only be included in the study after providing written (witnessed, where required by 
law or regulation), Independent Ethics Committee (IEC) approved informed consent or if patient is 
incapable of doing so, after such consent has been provided by a legally acceptable representative(s) of 
the patient. In cases the patient’s representative gives consent, the patient should be informed about the 
study to the extent possible given his/her understanding. If the patient is capable of doing so, he/she 
should indicate assent by personally signing and dating the written informed consent document.  
The process of obtaining informed consent should be documented in the patient source documents. 
Once the informed consent has been signed by the patient, a new patient file should be created in the 
electronic Case Report Form (eCRF) by the PI or the qualified person to whom this task has been 
delegated. Once the patient file is created, the patient is enrolled in the study and the eCRF system will 
automatically generate a trial number for this patient.  Once a number is assigned to a patient, the patient 
number can’t be re-used.  


 
 
 
 
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7.3 The randomisation scheme 
Randomized clinical trial with 2 treatment arms; therapy with high-dose loop diuretics and placebo vs 
therapy with high-dose loop diuretics and acetazolamide. An automated web-based system is used to 
randomly assign patients in a 1:1 ratio with variable blocks sizes, stratified for LVEF according to study 
center. To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the 
population will be stratified at inclusion according to LVEF ≤40% versus >40%. Permuted block 
randomisation according to center and LVEF stratum will be used to achieve this.  
Only the PI or qualified person to whom he/she has delegated this study task can randomize the patient 
in the automated web-based system. 
7.4 Blinding 
This is a double-blind study. Therefore, after randomization, the study team and patient will not be aware 
of which treatment (acetazolamide or placebo) is administrated to the trial participant.  
Once a patient is assigned to a study group (treatment group or control group), he/she will remain in that 
arm and all efforts will be made to provide the optimal therapy specified for that treatment assignment. In 
the unforeseen circumstance that this is clinically not feasible, the patient will remain in the assigned 
treatment arm for statistical analysis based on the intention-to-treat principle, as it represents a normal 
medical situation of success and failure of delivering the planned medical therapy. 
7.5 Unblinding 
Patient, site personnel, sponsor personnel and data analysts will remain blinded to the identity of the 
treatment from the time of randomization until database lock. Though we do not foresee serious adverse 
events related to the study drug, the study code should only be broken for valid medical or safety reasons 
e.g. in the case of a severe adverse event where it is necessary for the investigator or treating health care 
professional to know which treatment the patient is receiving before the participant can be treated. It is 
not mandatory but strongly encouraged to contact the chief investigator before unblinding any patients’ 
treatment assignment. Patient and members of the research team should remain blinded. 
Following rules apply for unblinding; 
 
Rapid unblinding of a patient can be performed by a physician of the study team. Detailed 
information concerning the unblinding procedures is provided in the Manual of Operations.  
 
On receipt of the treatment allocation details the PI or treating health care professional will 
continue to deal with the participant’s medical emergency as appropriate. 
 
The PI/Investigation team documents the breaking of the code and the reasons for doing so on 
the medical notes and eCRF. It will also be documented at the end of the trial in any final study 
report and/or statistical report. 


 
 
 
 
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 
the PI/Investigation team will notify the Sponsor in writing within one working day following the 
code break detailing the necessity of the code break. 
Randomization data are to be kept strictly confidential until the time of unblinding of the trial and will not 
be accessible by anyone else involved in the trial with the following exceptions: (1) the PM of the 
company responsible for the labelling and packaging of the IMP, (2) the IRT system programmers who 
work on the randomization and drug management system; and (3) the data manager who prepares 
reports required for regulatory reporting (suspected unexpected serious adverse reactions [SUSAR] 
reporting). These individuals will not be involved in the day-to-day running of the study. 
7.6 Screening phase assessments 
Screening testing will occur after the consent process has been finalized. The screening data gathering 
needs to be performed prior to the administration of the study diuretic agents. The following assessments 
are required and data need to be collected:  
 
Obtain written informed consent 
 
Check inclusion and exclusion criteria 
 
Collect demographics (collect age, gender, race and ethnicity) 
 
Collect medical history and notification of LVEF 
 
Collect concomitant medication: all chronic medication but only doses of neurohumoral blockers 
(ace-I, ARB, beta-blockers, spironolactone, eplerenone, sacubutril/valsartan) and diuretics (loop 
diuretics, thiazides) need to be recorded 
 
Collect vital signs including body weight, arterial blood pressure and heart rate 
 
EQ-5D patient questionnaire to be completed by the patient (Appendix 2 and 3) 
 
Perform volume assessment by 1 heart failure cardiologist who has been trained in the study 
volume assessment. Volume assessment is based on presence of oedema, ascites, pleural 
effusion (Figure 3 in section 8) 
 
Collect blood sample for local laboratory assessment: serum hemoglobin, hematocrit, electrolytes 
(Na, K, Cl, HCO3), serum osmolality, serum urea, serum Cr, total protein, serum albumin, Fe, 
ferritin, TSAT, LDH, troponin and plasma BNP or NT-proBNP.  
o 
In a subset of randomized patients participating in the laboratory sub-study blood 
collected during screening will be shipped to the University Biobank Limburg (see section 
7.10) 
 
Perform pregnancy urine test (applicable for all pre- menopausal women who are not surgically 
sterile, as well as women of childbearing potential) 
 
Randomization (see section 7.3) 
 
 


 
 
 
 
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7.7 Treatment phase assessments 
7.7.1 Day 1 
 
Request patient to empty their bladder before administration of the first dose of loop diuretics. 
 
Administer the first bolus of loop diuretics and acetazolamide or placebo to the patient.  
 
Start the urinary collection immediately after first bolus of loop diuretics and acetazolamide or 
placebo is administered. The collection will stop the latest as close to but prior to the morning 
bolus of study medication on day 3. Urinary catheter insertion is strongly recommended but not 
mandatory to achieve an optimal urine collection. However, in case of urinary incontinence, 
placement of a urinary catheter is mandatory. Care should be taken to ensure ALL urine is 
collected. For more details regarding the study urinary collection see appendix 4. 
Screening phase assessments and day 1 assessments are performed on the same day. If the patient 
is enrolled between midnight and 6 a.m., day 1 assessments and day 2 assessment can be 
performed on the same day but only if there is a difference of minimum 6 hours between the start of 
the study medication on day 1 and study medication on day 2.  
7.7.2 Day 2, Day 3 and Day 4 
 
Collect vital signs including body weight, arterial blood pressure, heart rate 
 
Perform volume assessment by 1 heart failure cardiologist who has been trained in the study 
volume assessment (Figure 3 in section 8) 
 
Collect morning blood sample for local laboratory assessment: serum haemoglobin, haematocrit, 
electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr, serum albumin.  
 
On the morning of Day 2 and Day 3, collect an urine sample from urine collection period 1 and 
period 2 respectively for analysis in local lab. In case patient is participating in the optional 
laboratory sub-study, collect an additional urine sample for each urine collection period for 
shipment to the University Biobank Limburg for storage and additional research (see section 
7.10). Urinary collection will stop at the morning of day 3 (appendix 4). 
 
In case patient is still volume overloaded continue study treatment as described in section 8 
 
Collect all new medication started, and doses of loop diuretics need to be recorded  
 
Document and assess adverse events (section 9) 
 
In addition, only on the morning day 4:  
o 
EQ-5D to be completed by the patient 
o 
Collect blood sample for local laboratory assessment of the BNP or NT-ProBNP level. In a 
subset of randomized patients participating in the laboratory sub-study blood collected on day 
4 will be shipped to the University Biobank Limburg (see section 7.10) 
o 
Collect all new medication started, and doses of neurohumoral blockers (ace-I, ARB, beta-
blockers, spironolactone, eplerenone, sacubutril/valsartan) need to be recorded  


 
 
 
 
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7.8 Follow-up phase assessments 
 
At Discharge: 
o 
Perform volume assessment by 1 heart failure cardiologist who has been trained in the study 
volume assessment (Figure 3 in section 8)  
o 
Collect weight  
o 
Record only neurohumoral blockers (ace-I, ARB, beta-blockers, spironolactone, eplerenone, 
sacubutril/valsartan) and diuretics (loop diuretics, thiazides) with their dosages  
o 
Document length of hospitalization 
o 
Document and assess adverse events (section 9) 
 
 
At Readmission: 
o 
HF readmissions are defined as either a hospital admission because of decompensated HF 
or an unscheduled contact at the emergency department if the patient is treated with 
intravenous loop diuretics. 
o 
During any readmission, EQ-5D questionnaire needs to be completed by the patient as soon 
as possible during the admission 
 
 
Long term follow-up 
Patients will be followed for a maximum of three months for secondary/tertiary endpoint analysis. 
This follow-up should not differ from standard of care for such patients. During one outpatient 
follow-up appointment 3 months (+ 14 days) after hospital discharge, standard of care data will be 
collected. The only study related tests will be a BNP / NT-ProBNP test and the collection of the EQ-
5D patient questionnaire. 
During this follow –up visit the following data will need to be collected: 
o 
Collect vital signs including body weight, arterial blood pressure, heart rate 
o 
EQ-5D patient questionnaire to be completed by the patient (Appendix 2 and 3) 
o 
Perform volume assessment by 1 heart failure cardiologist who has been trained in the study 
volume assessment (Figure 3 in section 8) 
o 
Collect blood sample for local laboratory assessment: serum hemoglobin, hematocrit, 
electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr, serum albumin, and plasma BNP or 
NT-proBNP. In a subset of randomized patients participating in the laboratory sub-study 
blood collected on this visit will be shipped to the University Biobank Limburg (see section 
7.10) 
o 
Record neurohumoral blockers (ace-I, ARB, beta-blockers, spironolactone, eplerenone, 
sacubutril/valsartan) and diuretics (loop diuretics, thiazides) with their dosages 
o 
Document and assess adverse events (section 9) 
We do not foresee that a significant amount of patients will be lost to follow-up as the follow-up 
period is short (max 3 months). The investigator should make every effort to contact participants 


 
 
 
 
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who are lost to follow-up. Attempts to contact such participants must be documented in the 
participant’s records. 
7.9 
Table of trial procedures 
 
Screening 
phase 
Treatment phase 
Follow up phase 
 
 
 
Study 
Day 1 
Morning 
of Study 
Day 2 
Morning 
of Study 
Day 3 
Morning 
of Study 
Day 4 
Discharge 
Re-
admission 
3 Months 
after study 
start dose 
Informed consent 
X 
 
 
 
 
 
 
 
In- and exclusion 
criteria 
X 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
Demographics1 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Vitals2 
X 
 
X 
X 
X 
 
 
X 
Weight12 
X 
 
X 
X 
X 
X 
 
X 
EQ5D 
X 
 
 
 
X 
 
X11 
X 
Volume 
assessment 
X 
 
X 
X 
X 
X 
 
X 
Study treatment 
 
X3 
X4 
X4 
 
 
 
 
Urinary 
collection5 
 
X 
X 
 
 
 
 
 
Local lab 
X6 
 
X7 
X7 
X7 
 
 
X7 
Laboratory sub-
study13 blood 
X 
 
 
 
X14 
 
 
X 
Laboratory sub-
study13 Urine 
 
X 
X 
 
 
 
 
 
Plasma BNP or 
NT-proBNP8 
X 
 
 
 
X 
 
 
X 
Urine pregnancy 
testing9 
X 
 
 
 
 
 
 
 
Dose of 
neurohumoral 
blockers 
X 
 
 
 
X 
X 
 
X 
Dose of diuretics 
X 
 
 
 
 
X 
 
X 
Concomitant 
medication 
X  
X 
X 
X 
X 
 
 
 
Adverse Events10  
X 
X 
X 
X 
X 
X 
X 
X 


 
 
 
 
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1) 
Age, race and ethnicity 
2) 
Arterial blood pressure and heart rate 
3) 
Start dose (IV) = 2 x orally daily maintenance dose of loop diuretics and 500 mg acetazolamide or placebo (see section 8) 
4) 
As long as patient is volume overloaded, Treatment dose (IV) = half of start dose of loop diuretics and 500 mg 
acetazolamide or placebo between 8:00 and 12:00 and a second dose minimum 6 hours later with half of the start dose of 
loop diuretics (see section 8) 
5) 
See appendix 4 
6) 
Serum hemoglobin, hematocrit, electrolytes (Na, K, Cl, HCO3), serum osmolality, serum urea, serum Cr, total protein, 
serum albumin, Fe, ferritin, TSAT, LDH and troponin 
7) 
Serum hemoglobin, hematocrit, electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr and serum albumin 
8) 
Protocol requires that plasma levels of BNP or NT-proBNP are collected. In case the patient is on succubutril/valsartan, it 
is mandatory that NT-proBNP plasma levels are determined on the blood sample. 
9) 
Only pre- menopausal women who are not surgically sterile, as well as women of childbearing potential. 
10) Safety reporting flow is documented in section 9 
11) EQ5-D needs to be collected once during any HF readmission (as soon as possible during readmission)) 
12) Measurement of body weight should be performed as consistently as poss ble using a standardized scale, preferably with 
a precision of 50 g, in the morning, post-void, prior to eating, prior to the medication dose, and with patients wearing the 
same clothing. The scales should stand on a flat, solid surface rather than carpets unless specifically designed for use in 
that setting 
13) Blood and urine will be collected in a subset of randomized patients participating in the laboratory sub-study. Blood will be 
collected on screening, day 4 and 3 month FU visit. Urine sample will be collected from Urinary Collection period 1 and 
Urinary collection period 2 (see also appendix 4). 
14) In case day 4 falls into a weekend or public holiday, blood collection for sub-study can also be done on day 5 or day 6. 
 
7.10 Laboratory sub-study 
Blood samples and urine samples from centers who agreed to participate in the Laboratory sub-study will 
be collected during the Advor trial. All potential patients at these centers will be asked to participate in the 
laboratory sub-study. An additional signed and dated informed consent must be obtained before the 
additional blood and urine samples will be collected.  
The right of a participant to refuse participation without giving reasons must be respected. The participant 
must remain free to withdraw at any time from this sub-study without giving reason and without 
prejudicing his/her further treatment and will be provided with a contact point where he/she may obtain 
further information about the sub-study. Where a participant is required to re-consent or new information 
is required to be provided to a participant it is the responsibility of the PI to ensure this is done in a timely 
manner. 
All patients enrolled in the laboratory sub-study will have blood collected on screening, day 4 and during 
the 3 month follow up visit. The collected blood samples will be shipped to the University Biobank 
Limburg for storage and additional research. A urine samples collected from the Urinary Collection period 
1 and from the Urinary Collection period 2 (see appendix 4) will be shipped to the University Biobank 
Limburg for storage and additional research. 
Biomarkers related to cardiac and renal function/injury will be obtained from blood and urine in the subset 
of patients participating in the laboratory sub-study. Biomarkers will be used to elucidate the effect of 
acetazolamide and to explore drug effect versus baseline biomarkers of risk. Biomarkers of potential 
interest are NT-proBNP, Galectin 3, ST2, Cystatin C and NGAL. The list of potential biomarkers may be 
changed or expand further as it is recognized that more relevant or novel biomarkers may be discovered. 
Biomarkers may be measured during the process of this study or after its completion. No genetic analysis 
will be performed with the collect sub-study samples. Detailed sample handling instructions will be 
provided in a separate laboratory manual.  


 
 
 
 
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7.11 Withdrawal criteria  
All subjects will be encouraged to remain on treatment and under observation for the full duration of the 
study. However, at any time during the study and without giving reasons, subjects may withdraw from the 
study at their own request or at the request of their legally acceptable representative. The subject will not 
suffer any disadvantage as a result.  
It is important to note that discontinuation of study treatment (see section 8) is not the equivalent to 
withdrawal of informed consent. In cases where subjects indicate they do not want to "continue", 
investigators must determine whether this refers to discontinuation of study treatment (the most common 
expected scenario), unwillingness to attend the follow-up visit, unwillingness to have telephone contact, 
unwillingness to have any contact with study personnel, or unwillingness to allow contact with a third party 
(e.g., family member, doctor). Every effort must be made to continue to follow the subject until the end of 
the study. 
In all cases, the reason for discontinuation (including "at the subject's request") must be recorded in the 
case report form (CRF) and in the subject's medical records. 
No subject replacements are permitted in the study. 
7.12 End of trial 
The Sponsor’s CTU ZOL will notify the FAMHP and main EC of the end of a clinical trial within 90 days of 
its completion date (last patient last visit).  
 


 
 
 
 
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8 TRIAL INTERVENTION / MEDICATION 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy 
with high-dose loop diuretics and placebo (standard of care - SOC) versus combination therapy with 
acetazolamide and high-dose loop diuretics in patients with decompensated heart failure and clinical 
signs of volume overload.  
8.1 Name and description of intervention(s) 
At randomization 
At the moment of randomization, oral loop diuretics are stopped and the patient receives an IV bolus of 
loop diuretics at a dose equal to the double of his oral daily maintenance dose* with a maximal dose of 5 
mg bumetanide (=200 mg furosemide). Bumetanide is the preferred loop diuretic agent to be used in this 
trial. 
Conversion factor:  
1 mg bumetanide po = 1 mg bumetanide IV 
40 mg furosemide po = 40 mg furosemide IV 
20 mg torsemide po = 40 mg furosemide IV = 1 mg bumetanide IV 
Some examples are listed below: 
- 
if a patient takes 1x1 mg bumetanide po, the patient will receive 2x1x1 mg = 2 mg bumetanide IV 
- 
if a patient takes 2x2,5 mg bumetanide po, the patient will receive 2x2x2,5 mg = 5 mg bumetanide IV 
- 
if a patient takes 1x40 mg furosemide po, the patient will receive 2x1x40 mg = 80 mg furosemide IV 
- 
If a patient takes 1x80 mg furosemide po, the patient will receive 2x1x80 mg = 160 mg furosemide IV 
- 
If a patient takes 1x20 mg torsemide po, the patient will receive 2x1x1 mg bumetanide IV= 2 mg 
bumetanide IV or 2x1x40 furosemide IV = 80 mg furosemide IV 
Together with this initial dose of loop diuretics patients will receive an intravenous bolus of 500 mg of 
acetazolamide or placebo. 
START DOSE (IV) = 2 x orally daily maintenance dose* of loop diuretics (max. 5 mg of 
bumetanide) 
+ 
500 mg acetazolamide or placebo 
*If the oral daily maintenance dose has changed over the week prior to admission, it will be 
defined as the highest orally administered daily dose that the patient has received in an outpatient context 
7 days prior to randomization. 
 
 
 
 


 
 
 
 
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During the treatment phase 
Between administering the start dose and next treatment dose a minimum of 6 hours is required. During 
the remaining part of the treatment phase, the patient will continue to receive 2 treatment doses every 
day provided that the treating physician has concluded during the morning rounds that the patient is still 
volume overloaded (see Figures 2+3). The dose will be half of the start dose given at randomization, 
administered between 8:00 and 12:00 am together with an intravenous bolus of 500 mg of acetazolamide 
or placebo. The second dose of loop diuretics, again half the start dose of loop diuretics, will be given 6 
hours after the morning dose. Any patient with more than trace oedema, residual pleural effusion (to be 
confirmed only if present at study inclusion), or residual ascites (to be confirmed only if present at study 
inclusion) would be considered to be still volume overloaded (see Figures 2 + 3). If the patient is not 
volume overloaded anymore, the intravenous administration of diuretics should be stopped and changed 
to an oral regimen. 
 
Between 8:00 and 12:00 am TREATMENT DOSE (IV) = START DOSE/2 (max. 5 mg of 
bumetanide) 
+  
500 mg acetazolamide or placebo 
6 hours later TREATMENT DOSE (IV) = START DOSE/2 
 
Figure 2. Flow chart to guide study. 
 
 
After treatment phase  
After the treatment phase, treating physicians are recommended not to prescribe oral acetazolamide as a 
maintenance diuretic therapy after decongestion; instead, they are encouraged to restart the original oral 
maintenance dose of loop diuretics of when the patient was still stable. Patients can be discharged as 
early as 24 hours after the physician concluded that the volume overload is no longer present. An  
outpatient follow-up appointment is scheduled at least 3 months (with a window of +14 days) after 
discharge and according to preferences of the treating physician. 


 
 
 
 
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STOP TREATMENT 
The treating physician is allowed to stop the study treatment, which counts as treatment failure in case of 
persistent volume-overload in following cases: 
- 
symptomatic hypotension with a systolic blood pressure <100 mmHg 
- 
asymptomatic hypotension with a systolic blood pressure <90 mmHg 
- 
an increase of serum Cr levels x 1.5 of the serum Cr level compared to admission value. 
- 
Occurrence of metabolic acidosis (ph < 7.2) 
If any of these events occur when the patient is judged to be euvolemic, the study treatment is stopped 
and stopping is not considered a treatment failure.  
Freedom from volume-overload (i.e.congestion) on the morning of day 4 will be defined as not 
more than trace oedema, no residual pleural effusion, and no residual ascites (Figure 3) 
 
Figure 3: Volume assessment 
 
 
 
 
 


 
 
 
 
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Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response  
If urinary output (see Figure 1 and Appendix 4) on morning of day 3 is < 3500 mL and the patient is still 
volume overloaded, an escalation of decongestive treatment is mandatory. Three options can be chosen 
at the discretion of the treating physician. 
Escalation therapy options: 
 
doubling of the IV dose of the loop diuretics (equal to the study start dose bid) 
 
add oral chlorthalidone 50 mg once daily 
 
ultrafiltration or renal replacement therapy might be considered 
The decision to proceed with escalation therapy needs to be collected in the case report form as the 
patient needing escalation cannot reach the primary endpoint. 
Background therapy  
24h oral intake of fluid and sodium will be restricted to 1500 mL and 1.5 g, respectively. All patients 
receive the same maintenance infusion with 500 mL glucose 5% and 3g MgSO4 administered over 24h 
time interval, until complete decongestion or end of the study treatment phase. All non-protocol fluids 
administered (including those for administration of intravenous medication) should be limited. 
In case of serum potassium levels <4 mmol/L, 40 mmol of KCI is added to the maintenance infusion. 
Oral potassium supplements may be used at the discretion of the treating physician, but their use will be 
prospectively registered. 
In case of metabolic acidosis with serum bicarbonate levels <20 mmol/L, it is recommended to 
administered intravenously 100 ml of NaHCO3 8.4%. 
Treatment with neurohumoral blockers (e.g. renin-angiotensin system blockers saccubutril/valsartan, 
beta-blockers, and mineralocorticoid receptor antagonists) may be continued at the same or lower 
dosage at the discretion of the treating physician, until the end of the treatment phase (max 4 days) or 
until complete decongestion is achieved, whatever comes first. Dose increases for any of these 
medications are not allowed during the screening and treatment phase with the exception of 
mineralocorticoid receptor antagonists in case of hypokalaemia despite intravenous potassium 
supplement. In addition, starting an SGLT2 inhibitor and a switch from renin-angiotensin system blockers 
to saccubutril/valsartan is not allowed during the screening and treatment phase, but might be pursued 
after decongestion is achieved. After decongestion, it is strongly recommended to up-titrate doses of 
neurohumoral blockers according to the guidelines in the HFrEF patients. Dosages of neurohumoral 
blockers are collected on admission, on discharge and at three months follow-up.  
 
 


 
 
 
 
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8.2 Legal status of the intervention  
The IMP (acetazolamide) is licensed for use in Belgium for the treatment of HF.  
 
8.3 Summary of Product Characteristics (SmPC) 
Information about common side effects already known about the investigational drug can be found in the 
SmPC filed in the Investigator Site File (ISF).  
SmPC in Dutch:  
http://bijsluiters.fagg-afmps.be/registrationSearchServlet?key=BE004137&leafletType=skp 
SmPC in French: 
http://bijsluiters.fagg-afmps.be/registrationSearchServlet?key=BE004137&leafletType=rcp 
8.4 Drug storage and supply  
The investigational medical product (IMP) (acetazolamide and placebo) will be shipped free of charge to 
the participating centers. The IMP must be received by a designated person in the pharmacy at the study 
center, handled and stored safely and properly, and kept in a secured location to which only the 
investigator and designees have access. Upon receipt, the PI or qualified delegated person will confirm 
the date of receipt of IMP. Receipt, distribution, return and destruction (if applicable) of the study drug 
must be properly documented according to the agreed and specified procedures. Specific instructions for 
the study drug recordkeeping are provided in the Manual of Operations. 
All IMP should be stored according to the instructions specified on the labels (room temperature below 
25°C).  
8.5 Preparation and labelling of Investigational Medicinal Product 
The IMPs (acetazolamide and placebo) will be presented as a white to off-white 500 mg powder for 
solution for injection in a sterile vial. Each study center will be supplied with study medication kits 
containing 3 vials of acetazolamide or placebo. Each kit will have an unique study kit number. The study 
medication supply will have appropriate labelled packaging according to national law of Good 
Manufacture Practices (GMP) ruling.  
Each IMP need to be reconstitute prior to use. Specific instructions will be provided in the Manual of 
Operations. The reconstituted solution is clear and colourless and does not contain an antimicrobial 
preservative. Any unused solution can be stored in a refrigerator for up to 24 hours but any solution not 
used within this period must be discarded. 
The direct intravenous route of administration is preferred. Intramuscular injection may be employed but 
is painful due to the alkaline pH of the solution. (preparation according to the SmPC see section 8.3) 


 
 
 
 
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8.6 Dosage schedules 
Cfr point 8.1 for specific dosage schedules and routes of administration. 
 
8.7 Dosage modifications  
Dosage modifications of the study drug are not possible as there will only be one dose (and the 
administration of the IMP vs placebo is blinded).  
8.8 Assessment of compliance 
As the study drug will be administered intravenously during the treatment phase (72 hours) by the nurse 
taking care of the patient, no compliance issues with regards to the study medication are foreseen.  
 
 


 
 
 
 
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9 SAFETY REPORTING 
As this is a pragmatic trial, the intervention will be used within the label and therefore safety reporting can 
be limited to the safety reporting which is necessary in routine care. 
Timely, accurate, and complete reporting of clinical events is of crucial importance for success of the 
study. Additionally, reporting and review of safety information for clinical studies are crucial for the 
protection of subjects.  
9.1 Definitions 
Term 
Definition 
Adverse Event (AE) 
Any untoward medical occurrence in a participant to whom a medicinal 
product has been administered, including occurrences which are not 
necessarily caused by or related to that product. 
Serious Adverse Event 
(SAE) 
A serious adverse event is any untoward medical occurrence that: 
 results in death 
 is life-threatening 
 requires inpatient hospitalisation or prolongation of existing 
hospitalisation 
 results in persistent or significant disability/incapacity 
 consists of a congenital anomaly or birth defect 
Other ‘important medical events’ may also be considered serious if 
they jeopardise the participant or require an intervention to prevent 
one of the above consequences. 
NOTE: The term "life-threatening" in the definition of "serious" refers to 
an event in which the participant was at risk of death at the time of the 
event; it does not refer to an event which hypothetically might have 
caused death if it were more severe. 
Suspected Unexpected 
Serious Adverse 
Reaction (SUSAR) 
A serious adverse reaction, the nature and severity of which is not 
consistent with the information about the medicinal product in question 
set out: 
 in the case of a product with a marketing authorisation, in the summary 
of product characteristics (SmPC) for that product 
 in the case of any other investigational medicinal product, in the 
investigator’s brochure (IB) relating to the trial in question 
 
9.2 Recording and reporting Safety Information 
During the course of this study, i.e. from signing the informed consent onwards until the end of the last 
follow-up visit, all SAEs, Endpoint Events and certain non-serious AEs which occurred until 3 months 
after study start dose are to be collected, documented, and reported by the Investigator in the applicable 
eCRF’s following below “safety reporting flow chart”: 
 
 


 
 
 
 
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Figure 4: Safety reporting flow chart 
 
How to assess Safety Events (AEs, SAEs and SUSARs) 
Seriousness, severity and causality need to be asses by the Principal Investigator or the physician to 
whom this activity is delegated to.  
 
An adverse event is defined as a serious adverse event if the event is any untoward medical 
occurrence that at any dose: 
 
Results in death 
 
Is life-threatening 
 
Requires inpatient hospitalization or prolongation of existing hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Is a congenital anomaly/birth defect, or 
 
Is an important medical event. 
Note: The term “life-threatening” in the definition of serious refers to an event in which the subject was at 
risk of death at the time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe  
The following definitions should be used to assess intensity of adverse events: 


 
 
 
 
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 
Mild: Awareness of sign or symptom, but easily tolerated, i.e., does not interfere with subject’s 
usual function. 
 
Moderate: Discomfort enough to cause interference with usual activity. 
 
Severe: Incapacitating with inability to work or do usual activity, i.e., interferes significantly with 
subject’s usual function. 
Severity vs. Seriousness: Severity is used to describe the intensity of a specific event whereas the event 
itself, however, may be of relatively minor medical significance (such as severe headache). This is not the 
same as "seriousness," which is based on subject/event outcome at the time of the event. 
The Investigator should assess causal relationship between an adverse event and the study drug 
on the basis of his/her clinical judgment, the latest SmPC (see section 8.3) and the following 
definitions. The causality assessment must be made based on the available information and can be 
updated as new information becomes available. 
Related: 
The AE follows a reasonable temporal sequence from study drug administration, and cannot be 
reasonably explained by the subject’s clinical state or other factors (e.g., disease under study, 
concurrent diseases, and concomitant medications). 
or 
The AE follows a reasonable temporal sequence from study drug administration, and is a known 
reaction to the drug under study or its chemical group, or is predicted by known pharmacology. 
Not Related: 
The AE does not follow a reasonable sequence from study drug administration, or can be 
reasonably explained by the subject’s clinical state or other factors (e.g., disease under study, 
concurrent diseases, and concomitant medications). 
 
Recording and reporting non-serious Adverse Events (AEs) 
AEs may be directly observed, reported spontaneously by the subject or by questioning the subject at 
each study visit. The Investigator must assess these AEs to determine seriousness, severity, and 
causality, in accordance with below definitions. The Investigator’s assessment must be clearly 
documented in the site’s source documentation. For the purposes of this study non-serious AEs that are 
related to the IMP or non-serious AEs that that occur in the cardiovascular system or non-serious 
AEs events involving imbalance of serum electrolytes (restricted to K+, Na+, HCO3) will be 
collected in the eCRF throughout the study. 
 
 


 
 
 
 
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Recording and reporting of SAEs AND SUSARs  
All SAEs an SUSARs will be collected throughout the study duration. Reporting of these events to the 
sponsor will occur on the eCRF AE page.   
Reporting of SAEs and SUSARs is mandatory and should start; 
- 
For SAEs, from consent 
- 
For SUSARs, from 1st IMP dose 
If the SAE is unexpected, i.e., the event is not previously documented as ‘expected’, and is thought to be 
related to the study drug, this event is considered a Suspected Unexpected Serious Adverse Reaction 
(SUSAR).  
Where a participant withdraws consent for further processing of data, this does not preclude the reporting 
of SAEs and SUSARs which are required to continue being reported according to the protocol for 
regulatory purposes.  
In all cases SAEs should be reported to the Sponsor in the eCRF. Only in case the investigator is of 
the opinion that the SAE is a SUSAR, the investigator needs to inform the sponsor within 24 hours 
after awareness of the event. Assessment of seriousness, causality and expectedness for trials 
involving IMPs will be made by the PI or another authorised doctor. If an authorised doctor from the 
reporting site is unavailable, initial reports without causality and expectedness assessment should be 
submitted to the Sponsor, but must be followed-up by medical assessment as soon as possible 
thereafter. 
For each SUSAR the following information will need to be collected: 
 
full details in medical terms and case description 
 
event duration (start and end dates, if applicable) 
 
action taken 
 
outcome 
 
seriousness criteria 
 
causality (i.e. relatedness to trial drug / investigation), in the opinion of the investigator 
 
whether the event would be considered expected or unexpected. 
All SAEs assigned by the PI or delegate (or following central review) as both suspected to be related to 
IMP-treatment and unexpected will be classified as SUSARs and will be subject to expedited reporting to 
the Federal agency for medicines and health products (FAMHP). The Sponsor will inform the FAMHP, the 
EC and the Marketing Authorisation Holder of SUSARs within the required expedited reporting 
timescales. 
 
 


 
 
 
 
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Endpoints 
The following events will need to be marked as an “endpoint event” in the eCRF: 
 
All-cause mortality:  All deaths from any cause. This includes all cardiovascular and non-
cardiovascular deaths. 
Cardiovascular death: Death fulfilling any of the following criteria: 
o 
Death due to proximate cardiac cause (e.g. myocardial infarction, cardiac tamponade, 
worsening heart failure) 
o 
Death caused by non-coronary vascular conditions such as neurological events, pulmonary 
embolism, ruptured aortic aneurysm, dissecting aneurysm, or other vascular disease 
o 
All procedure-related deaths, including those related to a complication of the procedure or 
treatment for a complication of the procedure (e.g. surgical or non-surgical revascularisation) 
o 
All valve-related deaths including structural or non-structural valve dysfunction or other valve 
related adverse events  
o 
Sudden death or unwitnessed death 
o 
Death of unknown cause 
 
Non-cardiovascular death: any death that is not thought to be due to a cardiovascular cause 
 
 
Rehospitalisation for heart failure is defined as either a hospital admission or an unscheduled contact 
at the emergency department for worsening HF if the patient is treated with intravenous loop 
diuretics.  
 
Rehospitalisation for a cardiac event 
 
Need for Renal replacement therapy: ultrafiltration or dialysis 
 
Submit complete endpoint package within 30 days of awareness to the sponsor. This package should 
Include anonymized source documents (SDs) relevant to the endpoint reported (e.g. discharge letter, 
emergency room notes, etc). The SD should include at least the reason for admission/death and the 
received treatment for the event (if applicable). The original SD need to be retained at the site.  
Identifying a pregnancy 
All pre- menopausal women who are not surgically sterile, as well as women of childbearing potential will 
have pregnancy urine tests performed at screening phase (Day 1). A positive pregnancy test at day 1 
constitutes in screen failure.  
 
 


 
 
 
 
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9.3 Responsibilities 
Principal Investigator (PI):  
Checking for AEs when participants attend for treatment / follow-up. 
1. Using medical judgement in assigning seriousness, causality and expectedness using the Reference 
Safety Information approved for the trial. 
2. Ensuring that all SAEs and SUSARs are recorded in the eCRF. Ensure that only SUSARs are reported 
to the Sponsor and the Chief Investigator within 24 hours of becoming aware of the event and provide 
further follow-up information as soon as available.  
3. Ensuring that AEs are recorded and reported to the Sponsor and the Chief Investigator in line with the 
requirements of the protocol.  
Chief Investigator (CI) / delegate or independent clinical reviewer: 
1. Clinical oversight of the safety of patients participating in the trial, including an ongoing review of the risk / 
benefit. 
2. Using medical judgement in assigning seriousness, causality and expectedness of SAEs where it has not 
been possible to obtain local medical assessment. 
3. Immediate review of all SUSARs.  
4. Review of specific SAEs in accordance with the trial risk assessment and protocol as detailed in the Trial 
Monitoring Plan. 
5. Assigning Medical Dictionary for Regulatory Activities (MedDRA) or Body System coding to all SAEs. 
6. Preparing the clinical sections and final sign off of the Development Safety Update Report (DSUR). 
Sponsor: 
1. Central data collection and verification of AEs, SAEs, and SUSARs according to the trial protocol onto a 
safety database.  
2. Reporting safety information to the CI, delegate or independent clinical reviewer for the ongoing 
assessment of the risk / benefit according to the Trial Monitoring Plan. 
3. Reporting safety information to the independent oversight committee identified for the trial (Trial Steering 
Committee (TSC)) according to the Trial Monitoring Plan. 
4. Expedited reporting of SUSARs to the Competent Authority (FAMHP IN be) and EC within required 
timelines. 
5. Notifying Investigators of SUSARs that occur within the trial. 
6. The unblinding of a participant for the purpose of expedited SUSAR reporting. 
7. Checking for (annually) and notifying PIs of updates to the Reference Safety Information for the trial. 


 
 
 
 
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8. Preparing standard tables and other relevant information for the DSUR in collaboration with the CI and 
ensuring timely submission to the FAMHP and EC. 
Trial Steering Committee (TSC):  
In accordance with the Trial Terms of Reference for the TSC, periodically reviewing safety data. 
9.4 Notification of deaths 
All deaths will be reported to the sponsor within 5 working days of the research staff becoming aware of 
the event with coding of the reason of death (HF related, non-HF related, unknown). In case the death is 
deemed related to the IMP the event will need to be reported within 24 hours of awareness of the event.  
9.5 Reporting urgent safety measures  
If any urgent safety measures are taken the CI/Sponsor shall immediately and in any event no later than 
3 days from the date the measures are taken, give written notice to the FAMHP and the relevant EC of 
the measures taken and the circumstances giving rise to those measures. 
9.6 The type and duration of the follow-up of subjects after adverse events 
Once an adverse event is detected, it should be followed until its resolution or until it is judged to be 
permanent, and assessment should be made at each visit (or more frequently, if necessary) of any 
changes in severity, the suspected relationship to the study treatment, the interventions required to treat 
it, and the outcome.   
All SUSARs occurring from the time of the start of trial treatment until end of follow-up study phase (3 
months) must be recorded in the eCRF within 24 hours of the investigational staff becoming aware of the 
event.   
9.7 Development safety update reports 
The CI will provide (in addition to the expedited reporting above) DSURs once a year throughout the 
clinical trial, or on request, to the Competent Authority (FAMHP in Belgium), Ethics Committee and 
Sponsor. 
The report will be submitted within 60 days of the Developmental International Birth Date (DIBD) of the 
trial each year until the trial is declared ended 
 
 


 
 
 
 
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10 STATISTICS AND DATA ANALYSIS 
The statistical analysis been planned together with Geert Molenberghs and Liesbeth Bruckers from 
CenStat - University Hasselt. 
10.1 Sample size calculation 
The ADVOR study is powered for primary end-point which is the most relevant end-point with respect to 
the study hypothesis and reliable data from large randomized clinical trials are available to make a formal 
power calculation.  
In the DOSE trial, which recruited a similar study population as targeted in the ADVOR study, successful 
decongestion with a similar definition was approximately 11% vs 18% after 72 h in the low vs high-dose 
loop diuretics arm.25 The high-dose loop diuretics arm of the DOSE trial is quite comparable to the 
standard of care group in the ADVOR study as the loop diuretic dose used in the latter is only slightly 
lower (2x instead of 2.5x the oral maintenance outpatient dose) and non-loop diuretics, which were 
infrequently used in the DOSE trial, are not allowed. Because of these slight differences, 15% is chosen 
as an estimate for occurrence of the primary end-point in the monotherapy with high-dose loop diuretics 
(SOC) group. 
No reliable data are available from large clinical trials to estimate occurrence of the primary end-point in 
the acetazolamide arm of the ADVOR study. Therefore, after thorough discussion with the advisory board 
as well as with Frank Hulstaert / Leen Verleye (KCE Trials) a success rate of 25% was chosen, which 
represents a clear meaningful benefit of 10% more patients with appropriate decongestion after 72 h. 
Using both estimates, considering a type I error rate α=0.05 and type II error rate β=0.20 (yielding a 
statistical power of 80%), the targeted sample size for the ADVOR study is calculated at n = 494. A 5% 
drop out has been calculated in order to estimate the total number of 519 patients to be enrolled in the 
study. 
10.2 Planned recruitment rate 
Patients will be recruited by approximately 24 Belgian sites within a period of approximately 24 months. 
The recruitment rate will start slow due to the site initiation activities at each center, which are performed 
in parallel during the first recruitment months. The inclusion criteria have been widened so almost all 
decompensated HF patients with volume overload might be suitable study candidates, which should lead 
to an easy recruitment of patients. In case recruitment would be lower than expected, the number of 
participating centers can be increased. Also, with the publication of three-monthly research letters to the 
participating sites and announcement through posters/leaflets of the ADVOR-study in the outpatient 
cardiology department, the inclusion process might be enhanced.  


 
 
 
 
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10.3 Statistical analysis plan 
 
The treatment effect for the primary end-point [Treatment success (decongestion achieved) on 
morning of day 4 without escalating diuretic strategy (doubling loop diuretic dose, addition of 
chlorthalidone, or ultrafiltration) during IV diuretic therapy on morning of day 3] is evaluated by means 
of a generalized linear mixed model. The statistical model will include a fixed treatment effect and 
random center effect. 
 
For the first secondary end-point [occurrence of  the combined endpoint of all-cause mortality and 
heart failure readmission during 3 months of follow-up], a generalized linear mixed model for a binary 
outcome will be used.  The model will incorporate a fixed treatment effect and random center 
effect.  If the treatment effect on the composite endpoint of ‘all-cause mortality and HF readmission’ 
turns out to be statistically significant, both components will be evaluated separately in a hierarchical 
fashion with HF readmissions first and all-cause mortality second. For this analysis, HF readmission 
will include patient dying from HF during the 3 months of FU. As a sensitivity analysis the worst case 
scenario, assuming a HF readmission for all patients dying to non HF related causes during the 3 
month follow-up will be executed. 
 
Length of index hospitalization and change in quality of life scores are compared among treatment 
arms with a linear mixed model (fixed treatment effect and random center effect). Transformation will 
be employed when the model assumptions (such normality) are violated.  
 
All hypothesis are 2-sided and tested with a significance level  of  α=0.05. 
The proposed statistical models all assume the missing data mechanism to be missing at random. To 
investigate the sensitivity of the conclusions with respect to this assumption, a sensitivity analysis by 
means of multiple imputation technique will be performed.  
Secondary Analysis: 
 
All statistical models discussed in the secondary analysis include a fixed treatment effect and 
random effect for the center, and in case of longitudinal outcome random patient effects (intercept, 
slope).  
 
The mixed models for the primary and secondary end-point analyses will be extended with 
explanatory variables (such as gender, age, race, ethnicity, kidney function, neurohumoral blockers, 
diuretics and blood pressure)  
 
For the end-points collected repeatedly over time, the rate of change will be investigated using 
longitudinal data models. 
 
In case patients are re-hospitalized more than once for the same reason, i.e. HF readmission, models 
for recurrent events will be employed.   
 
To study the treatment effect on the evolution of  a patient's weight a mixed model for repeated 
measurements data will be used. The two treatment arms will also be compared for the area under 
the weight curve using an ANOVA model.  


 
 
 
 
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 
For the first secondary end-point [time till combined endpoint of all-cause mortality and heart failure 
readmission during 3 months of follow-up], the Kaplan-Meier method will also be used to construct 
survival curves for both treatment arms. A mixed effects Cox proportional hazard model, with a fixed 
treatment effect and random center effect is used to investigate the treatment effect for this endpoint. 
The Hazard ratio with a 95% confidence interval will be obtained.  The appropriateness of the 
proportional hazard assumption will be examined. 
 
For the primary and secondary endpoint subgroups analysis, with subgroups defined on the basis of 
LVEF, will also be performed. 
10.4 Data collection for economic evaluation 
In Belgium 2% of the population has HF, with 15.000 new cases being diagnosed annually and 3% of the 
annual health care budget is spent on HF, of which most is related to recurrent hospitalization for 
decompensated HF. HF decompensation often with repeated hospitalization has a tremendous negative 
impact on quality of life of the patients. Additionally, patients compare an episode of decompensation with 
‘drowning’ so they are in constant fear of recurrent decompensations. 
Reducing the number of hospital admittances will have an impact on the health care budget but also 
reducing the length of hospital stay per admittance will have a positive impact. 
According to the “Technische Cel voor de verwerking van de gegevens met betrekking tot ziekenhuizen” 
(MKG- MFG data of 2014, DRG 194 Hartfalen), 21784 patients were hospitalized for heart failure with an 
average hospital stay of 12 days in 2014. The average hospitalization costed 7015,44 €/patient, making 
up a total amount of 152.824.344 €. Of these patients, 10854 patients were hospitalized with advanced 
symptoms (NYHA III and NYHA IV) with a considerable longer hospitalization duration (17.55 days) and 
higher costs (10 873,77€/patient). Cost was inclusive of hospital-day-care-price, fees and pharmaceutical 
products. 
According to the MZG department of hospital ”Ziekenhuis Oost Limburg AV” HF patients with “majeure or 
extreme” HF (comparable with NYHA III and NYHA IV) have an average hospital stay of 9,12 days which 
is significant less then MKG- MFG data available. This reduction of the length of a hospital stay is a result 
of our HF care giver project as well as the clinical adoption of the use of more effective decongestive 
therapies often including Acetazolamide. The protocol has been scientifically validated and has been 
published also in Acta Cardiologica which is a peer-reviewed Belgian Cardiology Journal ((Determinants 
and impact of the natriuretic response to diuretic therapy in heart failure with reduced ejection fraction and 
volume overload. Acta Cardiol. 2015 Jun;70:265-73 + Implementation of Transmural Disease 
Management in Patients Admitted with Advanced Heart Failure. Acta Cardiol. 2014;69:145- 54).). 
The ADVOR trial will evaluate whether adding a low cost medication (Diamox ® 8.28 € public price/vial) 
on top of the standard treatment will reduce the hospital stay of admitted HF patients with 25% as well as 
reduce the need for renal replacement strategy. In daily practice this would result in an additional cost of 
< 20€ to potentially reduce the average cost with at least 2500 € per hospitalised patient.This would also 
imply that acetazolamide, on top of usual care, has the potential to result in a direct cost saving of 


 
 
 
 
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38.203.690 € in Belgium (=25% reduction on the budget actually spent on HF hospitalization). 
Additionally, it’s estimated that a more thorough successful decongestion will also lead to a reduction in 
heart failure rehospitaliastion of 25% thereby further reducing health care cost. Therefore, a positive 
result of the ADVOR trial and wide adaptation of the therapeutic algorithm might translate into a reduction 
in expenses directly related to 1) a shorter hospitalization duration, 2) less costly ‘majeur or extreem’ HF, 
and 3) less HF hospitalizations. 
While these estimations might be considered ‘very optimistic’, they are merely a reflection of the potential 
impact of a reduction of hospitalisation duration as well as readmission seen in the Ziekenhuis Oost 
Limburg AV after implementation of the aforementioned care pathways including a better and faster 
decongestion with acetazolamide. However, assuming that the primary endpoint is reached (25% 
decongestion in the treatment group vs 15% in the standard of care), this would translate in a 11.7% 
relative risk reduction. If this would translate into a 11,7% reduction in heart failure related expenditure, an 
annual considerable cost-saving of 17.880.408 € might still be reached. 
Importantly, due to the off-patent status of the drug tested in ADVOR there will never be an industry 
sponsored trial to support this hypothesis. Therefore, ADVOR will lead to a revival of a “forgotten” 
medicine because it has the potential to significantly impact the way we treat congestion in heart failure 
patients. 
Finally, it’s expected that ADVOR will result in a novel innovative approach of treatment of 
decompensated HF which is focused at a different level of the nephron to achieve better, easier and safer 
decongestion. In that way ADVOR might pave the way towards a complete change in thinking with 
regards to treating decompensated heart failure. 
This protocol has been designed with a later possible economic analysis in mind. Therefore, economical 
evaluation of the trial will be possible as several variables will be collected; 
- 
HF readmission 
- 
Length of hospital stay 
- 
Need for renal replacement therapy 
- 
Longitudinal assessment of QoL (EQ5D)….. 
As for any further data analyses, an economic analysis can of course be conducted by the sponsor of the 
trial and the chief investigator, totally independent from KCE. 
In addition, an economic analysis can be part of a KCE health technology assessment (HTA) 
project.  HTA projects are conducted by KCE at its own costs as part of its annual work programme 
approved by the KCE board, and following the KCE processes. The decision for KCE to perform a HTA 
on the topic will depend on the trial results and the prioritisation of the topic among the topics introduced 
that year. Each KCE HTA project includes a literature review. Data from different studies may be 
included. A meta-analysis may be conducted for that purpose, including the results or the coded 
individual data of the funded trial. HTA projects are conducted internally at KCE or are outsourced to a 
certain extent using a public tender procedure. In any case, KCE uses external experts during the project. 


 
 
 
 
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For an HTA following a trial funded by KCE Trials, KCE would among others, invite the team of the chief 
investigator to act as external clinical experts to accompany the HTA project. 
 
 
 


 
 
 
 
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11 DATA HANDLING 
11.1 Data collection tools and source document identification 
It is the responsibility of the Principal Investigator at each site to maintain adequate and accurate source 
data, source documentation and CRFs to record all observations and other data pertinent to the clinical 
investigation in a timely manner. 
Patient’s personal data, which are included in the sponsor database shall be treated in compliance with 
all applicable laws and regulations. The data collected will be anonymized and the data will only be used 
for the purpose(s) of this trial.  
Source Data are defined as "All information in original records and certified copies of original records or 
clinical findings, observations, or other activities in a clinical trial necessary for the reconstruction and 
evaluation of the trial. Source data are contained in source documents (original records or certified 
copies)." 
Source Documents are defined as "Original documents, data and records (e.g., hospital records, clinical 
and office charts, laboratory notes, memoranda, subjects' diaries of evaluation checklists, pharmacy 
dispensing records, recorded data from automated instruments, copies or transcriptions certified after 
verification as being accurate and complete, microfiches, photographic negatives, microfilm or magnetic 
media, x-rays, subject files, and records kept at the pharmacy, at the laboratories, and at medico-
technical departments involved in the clinical trial)." 
Case report form (CRF) is a form on which individual patient data required by the trial protocol are 
recorded.   
All data relating to the trial must be recorded in the eCRF prepared by the Sponsor. Data reported in the 
eCRF should be in English, consistent with the source data or the discrepancies should be explained. If 
information is not known, this must be clearly indicated in the eCRF. All missing and ambiguous data will 
be queried. 
The study data will be transcribed by study personnel from the source documents onto an eCRF, within 5 
working days of the subject’s visit.  
Worksheets may be used for the capture of some data to facilitate completion of the eCRF. Any such 
worksheets will become part of the subjects’ source documentation..  
Every effort should be made to ensure that all subjective assessments to be recorded in the eCRF are 
performed by the same individual who made the initial screening assessment.  
The Investigator must verify that all data entries in the eCRF are accurate and correct. All eCRF entries, 
corrections, and alterations must be made by the Investigator or other authorized study-site personnel. 
The Investigator or an authorized member of the investigational staff must adjust the eCRF (if applicable) 
and complete the query.  


 
 
 
 
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ADVOR uses an eCRF which will be used to perform statistical analysis for the trial. The CRF will be 
constructed to ensure: 
 
adequate data collection  
 
proper trails will be kept to demonstrate the validity of the trial (both during and after the trial) 
 
that only the data required by the protocol are captured in the CRF 
An annotated CRF is developed with coding convention as will be used in the database. 
The Principal investigator is responsible to keep records of all participating patients (sufficient information 
to link records e.g., CRFs, hospital records and samples), all original signed informed consent forms and 
copies of the CRF pages. 
11.2 Data handling and record keeping 
All collected study data will be recorded in the CRF created with the software of CASTOR EDC.  
CASTOR EDC complies with all applicable medical data privacy laws and regulations: GCP, 21 CFR Part 
11, EU Annex 11, the European Data Protection Directive, ISO9001, and ISO27001/NEN7510.  
Once the PI and delegated member(s) of the investigational staff have been trained, they will receive the 
link of the eCRF together with a log-in account and password. Detailed information regarding the eCRF is 
provided in the Manual of Operations. 
Besides the data entered in the CRF, source documentation will need to be transferred to the sponsor if 
an endpoint (see section 9) has been reported. Only anonymised sourced data and in accordance with 
the Belgian Privacy Act of 8 December 1992 and the European Data Protection Act should be transferred 
to the sponsor. Detailed information regarding the transfer of source documents to the sponsor is 
provided in the Manual of Operations. 
11.3 Access to Data 
Direct access will be granted to authorised representatives from the Sponsor, host institution and the 
regulatory authorities to permit trial-related monitoring, audits and inspections. 
11.4 Archiving 
 
archiving will be authorised by the Sponsor following submission of the end of study report 
 
It is the responsibility of the Principal Investigator at each site to ensure all essential trial 
documentation and source records (e.g. signed Informed Consent Forms, Investigator Site 
Files, patients’ hospital notes, etc.) at their site are securely retained for at least 20 years 
 
The sponsor will be responsible for archiving all CRF documents and trial database for at least 
20 years 
 
Therefore, all essential documents will be archived for a minimum period after completion of trial 
as required by the applicable legislation 
 


 
 
 
 
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12 MONITORING, AUDIT & INSPECTION 
A Trial Monitoring Plan will be developed and agreed by the TMG based on the trial risk assessment 
which will be done by exploring the trial dataset or performing site visits. 
The Sponsor will perform on-site monitoring visits as frequently as necessary. The monitor will record 
dates of the visits in a study center visit log that will be kept at the site. The first post-initiation visit will be 
made as soon as possible after enrollment at the center has begun. Monitoring might be initially 
conducted across all sites, and subsequently conducted using a risk based approach that focuses, for 
example, on sites that have the highest enrolment rates, large numbers of withdrawals, or atypical (low or 
high) numbers of reported adverse events. At these visits, the monitor will compare the data entered into 
the CRFs with the hospital or clinic records (source documents). The nature and location of all source 
documents will be identified to ensure that all sources of original data required to complete the CRF are 
known to the Sponsor, Chief Investigator and investigational staff and are accessible for verification by 
the Sponsor site contact. If electronic records are maintained at the investigational site, the method of 
verification must be discussed with the investigational staff. The processes reviewed can relate to 
participant enrolment, consent, eligibility, and allocation to trial groups; adherence to trial interventions 
and policies to protect participants, including reporting of harm and completeness, accuracy, and 
timeliness of data collection 
Direct access to source documentation (medical records) must be allowed for the purpose of verifying 
that the data recorded in the CRF are consistent with the original source data, patients informed consent 
will be obtained hereto. Findings from this review of CRFs and source documents will be discussed with 
the investigational staff. The Sponsor expects that, during monitoring visits, the relevant investigational 
staff will be available, the source documentation will be accessible, and a suitable environment will be 
provided for review of study-related documents. The monitor will meet with the Investigator on a regular 
basis during the study to provide feedback on the study conduct.  
 
 
 


 
 
 
 
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13 ETHICAL AND REGULATORY CONSIDERATIONS 
13.1 Ethics Committee (EC) review & reports 
 
Before the start of the trial, approval will be sought from a EC for this trial protocol, informed 
consent forms and other relevant documents e.g. insurance documents, advertisements and 
GP information letters 
 
Substantial amendments that require review by EC will not be implemented until the EC grants 
a favourable opinion for the study (note that amendments may also need to be reviewed and 
accepted by the FAMHP before they can be implemented in practice at sites) 
 
All correspondence with the EC will be retained in the Trial Master File/Investigator Site File  
 
An annual progress report (APR) will be submitted to the EC within 30 days of the anniversary 
date on which the favourable opinion was given, and annually until the trial is declared ended 
 
It is the Chief Investigator’s responsibility to produce the annual reports as required. 
 
The Chief Investigator will notify the EC of the end of the study 
 
If the study is ended prematurely, the Chief Investigator will notify the EC, including the reasons 
for the premature termination 
 
Within one year after the end of the study, the Chief Investigator will submit a final report with 
the results, including any publications/abstracts, to the EC 
13.2 Peer review 
The protocol has been reviewed by KCE (the funder). 
In addition, ADVOR has undergone a high quality peer review by two individual experts who have 
knowledge of the relevant discipline to consider the clinical and/or service based aspects of the protocol, 
and/or have the expertise to assess the methodological and statistical aspects of the study.  
13.3 Public and Patient Involvement 
At least 2 % of the Belgian population has heart failure (HF), with 15.000 new cases being diagnosed 
annually and 3% of the annual health care budget spent on HF, the most of which is related to recurrent 
hospitalization for decompensated HF. These hospitalizations have a tremendous negative impact on the 
quality of life of patients.  
Therefore, ADVOR will be a RCT with patient and public involvement at all stages of the clinical research. 
Indeed, ADVOR actually is a result of an active partnership between patients, members of the public 
including KCE / health care administrators, and researchers in the research process. More specifically.  
all endpoints of ADVOR are patient-centric measures (i.e.primary endpoint of decongestion) with a formal 
power calculation. Unfortunately, powering a study for hard cardiovascular endpoints would need 


 
 
 
 
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thousands of patients with corresponding budgets and would not be feasible within the Belgian context. 
Fortunately, successful decongestion (i.e. free of volume overload) has been proved study after study to 
be a relevant clinical outcome strongly associated with overall prognosis and was therefore chosen as the 
primary end-point for the ADVOR trial. It’s also very patient relevant. In addition, secondary endpoints: all-
cause mortality, HF readmission length of stay, and QoL are also very patient-centric.  
In addition, the primary and secondary outcome measures are in line with the COMET (Core Outcome 
Measures in Effectiveness Trials) initiative. Indeed ‘decongestion’ (being dry is for the patient a very 
important improvement in symptomatology), heart failure readmission, all-cause mortality, length of stay, 
quality of life….can all be considered standardised relevant core outcomes sets. Therefore, the core 
outcomes relevant for any acute heart failure study will be collected and reported, making it easier for the 
results of ADVOR to be compared, contrasted and combined as appropriate with other trials (Zannad F et 
al, European Journal of Heart Failure, 2013;15:1082-1094). Additionally, we will continue to explore other 
tertiary outcomes, which are often mechanistically very interesting, as well. 
The protocol has also been discussed with members of “Mon Coeur Entre Parenthèses” which is a 
patient association representing HF patients and their family. 
We will also collect the dosages of neurohumoral blocker therapy throughout the study period, thereby 
hopefully facilitating a better implementation of guideline recommended therapy. As guidelines 
recommend a specific dosage for each of these drugs, it’s easy to standardize the intake of such 
medications to be used in an accurate analysis. This will be done as an exploratory tertiary end-point. 
Finally, strategies that reduce the number of hospital admittances / length of stay will have an immediate 
impact on the health care budget.  
13.4 Regulatory Compliance  
The trial will not commence until a Clinical Trial Authorisation (CTA) is obtained from the FAMPH and EC. 
The protocol and trial conduct shall be governed and construed in accordance with the laws of Belgium. 
The Trial will for instance comply with the Belgian law of May 7th 2004 regarding experiments on the 
human person and any relevant amendments. 
The validity, interpretation and performance of this Protocol shall be governed and construed in 
accordance with the laws of Belgium. Belgian courts have the exclusive jurisdiction.  
13.5 Protocol compliance  
Protocol deviations, non-compliances, or breaches are departures from the approved protocol. 
 
Prospective, planned deviations or waivers to the protocol are not allowed and must not be used 
e.g. it is not acceptable to enrol a subject if they do not meet the eligibility criteria or restrictions 
specified in the trial protocol 


 
 
 
 
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 
Accidental protocol deviations can happen at any time. They must be adequately documented 
and explained on the relevant forms and reported to the Chief Investigator and Sponsor 
immediately.  
 
Deviations from the protocol which are found to frequently recur are not acceptable, will require 
immediate action and could potentially be classified as a serious breach. 
 
13.6 Notification of Serious Breaches to GCP and/or the protocol  
A “serious breach” is a breach which is likely to effect to a significant degree 
 
the safety or physical or mental integrity of the subjects of the trial; or 
 
the scientific value of the trial 
 
The sponsor and the Chief Investigator will be notified immediately of any case where the above definition 
applies during the trial conduct phase. 
The sponsor of the clinical trial will notify the licensing authority in writing of any serious breach of the 
conditions and principles of GCP in connection with that trial; or the protocol relating to that trial, as 
amended from time to time, within 7 days of becoming aware of that breach. 
13.7 Data protection and patient confidentiality  
All investigators and trial site staff must comply with the requirements of the Regulation (EU) 2016/679 of 
April 27, 2016 of the European Parliament and the Council Concerning the protection of individuals with 
regard to the processing of personal data and the free movement of such data and repealing Directive 
95/46 / EC ( general data Protection Regulation) and the Belgian Privacy Act of 8 December 1992 on the 
protection of privacy in relation to the processing of personal data and the European Data Protection Act. 
with regards to the collection, storage, processing and disclosure of personal information and will uphold 
the Act’s core principles.  
Therefore, 
 
personal information will be collected, kept secure, and maintained in a way that is conform all 
regulation concerning privacy  
 
the creation of coded, depersonalised data where the participant’s identifying information is 
replaced by an unrelated sequence of characters 
 
secure maintenance of the data and the linking code in separate locations using encrypted digital 
files within password protected folders and storage media 
 
limiting access to the minimum number of individuals necessary for quality control, audit, and 
analysis with a list of persons who have access to data, and all this conform the regulation 
concerning privacy 
 
the confidentiality of data will be preserved when the data are transmitted to sponsors and co-
investigators 
 
the data will be stored for at least 20 years 


 
 
 
 
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 
The data custodians are are prof. dr. Mullens, Evi Theunissen and Joke Vanlangenaeker. 
13.8 Financial and other competing interests for the chief investigator, PIs at each site 
and committee members for the overall trial management  
As acetazolamide is an off-patent drug, no competing interests that might influence trial design, conduct, 
or reporting are present for any of the chief investigator, PIs at each site and committee members for the 
overall trial management. 
13.9 Indemnity 
1. The Sponsor will ensure appropriate insurance to meet the potential legal liability of the Sponsor(s) for 
harm to participants arising from the management of the research. Before the start of the trial, approval 
will be sought from the EC. 
2.  The Sponsor will ensure appropriate insurance for legal liability of the Sponsor(s) or employer(s) for 
harm to participants arising from the design of the research. Before the start of the trial, approval will be 
sought from the EC. 
3. The participating sites will ensure appropriate insurance to meet the potential legal liability of 
investigators/collaborators arising from harm to participants in the conduct of the research. 
13.10 Access to the final trial dataset 
Only the steering group has access to the full trial dataset in order to ensure that the overall results are 
not disclosed by an individual trial site prior to the main publication.  
However, site investigators will be allowed to access the full dataset if a formal request describing their 
plans is approved by the steering group. 
 
 


 
 
 
 
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14 DISSEMINATION POLICY 
14.1 Dissemination policy 
Upon completion,  
 
the data arising from the trial will be owned by the sponsor 
 
the data will be analysed and tabulated and a Final Study Report prepared 
 
the full study report can be accessed on the website of KCE as well as on ClinicalTrials.gov 
 
participating investigators will have rights to publish any of the trial data upon approval of the 
steering committee 
 
The publication containing the primary study results should be finalized within 6 months of the 
statistical analysis. There are no time limits or review requirements on the additional 
publications. 
 
Funding by KCE will be acknowledged within the publications  
 
The participants of the trial will be notified by a letter containing the outcome of the trial by 
provision of the publication and/or via a specifically designed newsletter 
 
The participant might specifically request results from their PI upon completion of the trial, which 
might be provided once the results have been published  
 
It’s foreseen that at the latest at publication, a machine readable electronic copy of the 
published version or final peer-reviewed manuscript accepted for publication in a repository for 
scientific publications will be deposit (open access). The research data needed to validate the 
results presented in the scientific publications will be deposited. 
Upon completion, the study will also be submitted for presentation at the annual European Society of 
Cardiology in the late-breaking Clinical Trial Session as well as during the Annual European Heart Failure 
Association meeting. 
The primary study results of ADVOR will be reported fully and made publicly available when the research 
has been completed. All researchers shall ensure that the outcome of the research is prepared as a 
research paper for publication in a suitable peer-reviewed, preferably open-access, journal. In addition, 
the database of the ADVOR study will be available for further sub-analysis per request of any of the sub-
investigators. As a result, we feel that at least 10 other publications might be possible based on the data 
collected in ADVOR study which might all help to treat decompensated HF patients better. The Consort 
Guidelines and checklist will be reviewed prior to generating any publications for the trial to ensure they 
meet the standards required for submission to high quality peer reviewed journals etc. 
http://www.consort-statement.org/ 
All participating investigators will also try to disseminate their research findings to the broader public as 
well as to the research participants when the study has completed. 


 
 
 
 
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Endpoints were meticulously chosen based on consensus of all participating investigators including 
European Heart Failure Association as well as HF patient organisation (Mon Coeur Entre Parenthèses). 
Therefore, a positive result will also have the potential to be adopted soon in the national and 
international guidelines to treat decompensated HF patients.  
In conclusion, it’s felt that a positive endpoint might lead to a fast adoption of the use of acetazolamide in 
the treatment of ADHF patients because of 
1) Publication in top ranked cardiology journal 
2) Presentation of study results in national and international cardiology meetings 
3) Adoption in guidelines 
4) Internationally recognized expert study team 
14.2 Authorship eligibility guidelines and any intended use of professional writers 
For ADVOR, the Steering Committee will comprise the Publication Committee. KCE may serve as 
members of the committee. This committee will manage study publications with the goal of publishing 
findings from the data. The Publication Committee will develop the final Publication Plan as a separate 
document. In addition, the committee will apply and reinforce the authorship guidelines set forth in the 
Publication Plan. Membership in the Publication Committee does not guarantee authorship. The 
committee will meet at regular intervals. 
Publications will adhere to authorship criteria defined by the International Committee of Medical Journal 
Editors (ICMJE, Uniform requirements for manuscripts submitted to biomedical journals, www.icmje.org). 
Individual authorship criteria defined by the target journal or conference will be followed when it differs 
from ICMJE criteria. Authors, including KCE representatives, must at a minimum meet all of the 
conditions below: 
 
Substantial contribution to conception and design, or acquisition of data, or analysis and 
interpretation of data; AND 
 
Drafting the article or revising it critically for important intellectual content; AND 
 
Final approval of the version to be published; AND 
 
Agreement to be accountable for all aspects of the work in ensuring that questions related to the 
accuracy or integrity of any part of the work are appropriately investigated and resolved. 
Decisions regarding authorship and contributorship will be made by the committee. The selected authors 
will be responsible for drafting the publication. All selected authors must fulfill the authorship conditions 
stated above to be listed as authors, and all contributors who fulfill the conditions must be listed as 
authors. 
All investigators not listed as co-authors will be acknowledged as the “ADVOR Study Investigators” and 
will be individually listed according to the guidelines of the applicable scientific journal when possible. Any 
other contributors will be acknowledged by name with their specific contribution indicated. Based on the 
recruitment, site investigators might also be part of the Authorship.  
 


 
 
 
 
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A methods paper describing the ADVOR study, as well as the publication containing the primary study 
results will be drafted by the Chief Investigator, and submitted for publication after approval of the 
members of the steering committee.  
 
 


 
 
 
 
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15 REFERENCES 
1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, 
Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela 
BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar 
DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie 
PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D and Turner MB. Heart disease and stroke 
statistics 2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-e245. 
2. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive 
heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293-302. 
3. Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, 
Wong M and et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of 
chronic congestive heart failure. N Engl J Med. 1991;325:303-10. 
4. Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM and Shusterman NH. The 
effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol 
Heart Failure Study Group. N Engl J Med. 1996;334:1349-55. 
5. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353:9-13. 
6. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial 
in Congestive Heart Failure (MERIT-HF). Lancet. 1999;353:2001-7. 
7. Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne 
A, Roecker EB, Schultz MK and DeMets DL. Effect of carvedilol on survival in severe chronic heart 
failure. N Engl J Med. 2001;344:1651-8. 
8. Flather MD, Shibata MC, Coats AJ, Van Veldhuisen DJ, Parkhomenko A, Borbola J, Cohen-Solal A, 
Dumitrascu D, Ferrari R, Lechat P, Soler-Soler J, Tavazzi L, Spinarova L, Toman J, Bohm M, Anker 
SD, Thompson SG and Poole-Wilson PA. Randomized trial to determine the effect of nebivolol on 
mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur 
Heart J. 2005;26:215-25. 
9. Cohn JN and Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic 
heart failure. N Engl J Med. 2001;345:1667-75. 
10. Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, 
Yusuf S, Pocock S, Investigators C and Committees. Effects of candesartan on mortality and 
morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet. 
2003;362:759-66. 
11. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J and Wittes J. The effect of 
spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone 
Evaluation Study Investigators. N Engl J Med. 1999;341:709-17. 
12. Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ and 
Pitt B. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 
2011;364:11-21. 


 
 
 
 
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13. Swedberg K, Komajda M, Bohm M, Borer JS, Ford I, Dubost-Brama A, Lerebours G, Tavazzi L and 
Investigators S. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-
controlled study. Lancet. 2010;376:875-85. 
14. McMurray JJ, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon 
SD, Swedberg K, Zile MR, Investigators P-H and Committees. Angiotensin-neprilysin inhibition versus 
enalapril in heart failure. N Engl J Med. 2014;371:993-1004. 
15. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets 
D, White BG, DeVries DW and Feldman AM. Cardiac-resynchronization therapy with or without an 
implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140-50. 
16. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L and Tavazzi L. The 
effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 
2005;352:1539-49. 
17. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA, 3rd, Foster E, 
Greenberg H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D and Zareba W. Cardiac-
resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009;361:1329-
38. 
18. Tang AS, Wells GA, Talajic M, Arnold MO, Sheldon R, Connolly S, Hohnloser SH, Nichol G, Birnie 
DH, Sapp JL, Yee R, Healey JS and Rouleau JL. Cardiac-resynchronization therapy for mild-to-
moderate heart failure. N Engl J Med. 2010;363:2385-95. 
19. Adams KF, Jr., Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR, Abraham WT, Berkowitz 
RL, Galvao M and Horton DP. Characteristics and outcomes of patients hospitalized for heart failure 
in the United States: rationale, design, and preliminary observations from the first 100,000 cases in 
the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2005;149:209-16. 
20. Forman DE, Butler J, Wang Y, Abraham WT, O'Connor CM, Gottlieb SS, Loh E, Massie BM, Rich 
MW, Stevenson LW, Young JB and Krumholz HM. Incidence, predictors at admission, and impact of 
worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 
2004;43:61-7. 
21. Testani JM, Chen J, McCauley BD, Kimmel SE and Shannon RP. Potential effects of aggressive 
decongestion during the treatment of decompensated heart failure on renal function and survival. 
Circulation. 2010;122:265-72. 
22. Testani JM, Cappola TP, Brensinger CM, Shannon RP and Kimmel SE. Interaction between loop 
diuretic-associated mortality and blood urea nitrogen concentration in chronic heart failure. J Am Coll 
Cardiol. 2011;58:375-82. 
23. Testani JM, Kimmel SE, Dries DL and Coca SG. Prognostic importance of early worsening renal 
function after initiation of angiotensin-converting enzyme inhibitor therapy in patients with cardiac 
dysfunction. Circ Heart Fail. 2011;4:685-91. 
24. Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V, Piovanelli B, Carubelli V, Bugatti S, 
Lombardi C, Cotter G and Dei Cas L. Is worsening renal function an ominous prognostic sign in 
patients with acute heart failure? The role of congestion and its interaction with renal function. Circ 
Heart Fail. 2012;5:54-62. 


 
 
 
 
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25. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, 
Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, 
Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E and O'Connor CM. Diuretic 
strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797-805. 
26. Schnermann J. Juxtaglomerular cell complex in the regulation of renal salt excretion. Am J Physiol. 
1998;274:R263-79. 
27. Knauf H and Mutschler E. Sequential nephron blockade breaks resistance to diuretics in edematous 
states. J Cardiovas Pharmacol. 1997;29:367-72. 
28. Verbrugge FH, Dupont M, Bertrand PB, Nijst P, Penders J, Dens J, Mullens W. Determinants and 
impact of the natriuretic response to diuretic therapy in heart failure with reduced ejection fraction and 
volume overload. Acta cardiologica. 2015;70:265-73. 
29. Knauf H, Mutschler E. Sequential nephron blockade breaks resistance to diuretics in edematous 
states. J Cardiovasc Pharmacol. 1997;29:367-72. 
30. Mullens W, Verbrugge FH, Nijst P, Tang WH. Renal sodium avidity in heart failure: from 
pathophysiology to treatment strategies. Eur Heart J. 2017 2017;38:1872-1882. 
31. Lala A McNulty SE, Mentz RJ, et al. Relief and recurrence of congestion during and after 
hospitalization for acute heart failure: insights from diuretic optimization strategy evaluation in acute 
decompensated heart failure 'DOSE-AHF) and cardiorenal rescue study in acute decompensated 
heart failure (CARRESS-HF). Circ Heart Fail. 2015;8:741-8. 
32. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in 
the emergency diagnosis of heart failure. N Engl J Med 2002;347:161-7 
33. Januzzi JL, Jr., Camargo CA, Anwaruddin S, et al. The N-terminal Pro-BNP. Investigation of Dyspnea 
in the Emergency department (PRIDE) study. Am J Cardiol 2005;95:948-54. 
 
 
 


 
 
 
 
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 APPENDICES 
 
16 APPENDIX 1: AUTHORISATION OF PARTICIPATING SITES  
Appendix 1.1. Required documentation  
Prior to submitting the trial to the Ethics Committee, the Principal Investigator (PI) is required to sign a 
protocol signature page confirming his/her agreement to conduct the trial in accordance with these 
documents and all of the instructions and procedures found in this protocol. 
Detailed information regarding the mandatory documentation which are required before the trial can start 
at the participating sites can be found in the Manual of Operations. 
Appendix 1.2. Procedure for initiating/opening a new site  
Once all start-up documentation (see Manual of Operations) from the participating site is available at the 
sponsor and the IMP/study material is available at the participating site, the sponsor will send 
confirmation by e-mail to the PI that the study can start. Only upon receipt of this site activation 
confirmation the site can screen/enrol patients.  
Appendix 1.3. Principal Investigator responsibilities  
The PI is the responsible leader of the investigational team of the participating site. The PI is responsible 
that he/she and his/her investigational team conducts the trial according the instructions and procedures 
documented in this protocol.  Full list of PI’s legal responsibilities are listed in the Clinical Trial Agreement. 
The PI has the primary responsibility to protect the rights and welfare of the patient in the trial. The PI’s 
primary responsibilities also include the following: 
- Delegation of Responsibilities 
PI must personally perform or delegate to qualified sub-investigator or investigational staff all of the 
necessary tasks to carry out this trial.  Even when specific tasks are delegated, the PI remains 
ultimately responsible for proper conduct of the trial and fulfilment of all associated obligations. 
- Oversight of Investigational Team 
The PI must provide members of the investigational team with sufficient oversight, training and 
information to facilitate appropriate safety procedures and protocol adherence. In addition, the EC 
must be informed if a PI is no longer able to 67ulfil his or her duties for any reason including, but not 
limited to, traveling for a prolonged period of time. 
- Evaluation of Adequacy of Resources 
Pis must ensure that adequate resources (facilities, equipment, supplies, and personnel) exist to 
conduct the research, protect subjects and ensure the integrity of the research. 


 
 
 
 
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- Document Retention 
The PI must ensure adequate and accurate source documents and trial records that include all 
pertinent observations on each of the site’s trial patients. Source data should be attributable, legible, 
contemporaneous, original, accurate and complete. PI must ensure that this source data is reported 
to the sponsor in the CRF and in the required reports according to the timelines defined in this 
protocol. 
 
 
 
 


 
 
 
 
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17 APPENIX 2: EQ-5D QUESTIONNAIRE (DUTCH) 
 
Vink onder elke titel het ENE vakje aan dat het best uw gezondheid VANDAAG beschrijft. 
MOBILITEIT 
 
Ik heb geen problemen met rondwandelen 
 
Ik heb een beetje problemen met rondwandelen 
 
Ik heb matige problemen met rondwandelen 
 
Ik heb ernstige problemen met rondwandelen 
 
Ik ben niet in staat om rond te wandelen 
 
ZELFZORG 
 
Ik heb geen problemen met mijzelf te wassen of aan te kleden 
 
Ik heb een beetje problemen met mijzelf te wassen of aan te kleden 
 
Ik heb matige problemen met mijzelf te wassen of aan te kleden 
 
Ik heb ernstige problemen met mijzelf te wassen of aan te kleden 
 
Ik ben niet in staat mijzelf te wassen of aan te kleden 
 
DAGELIJKSE ACTIVITEITEN (bijv. werk, studie, huishouden, gezins- en 
vrijetijdsactiviteiten) 
 
Ik heb geen problemen met mijn dagelijkse activiteiten 
 
Ik heb een beetje problemen met mijn dagelijkse activiteiten 
 
Ik heb matige problemen met mijn dagelijkse activiteiten 
 
Ik heb ernstige problemen met mijn dagelijkse activiteiten 
 
Ik ben niet in staat mijn dagelijkse activiteiten uit te voeren 
 
PIJN / ONGEMAK 
 
Ik heb geen pijn of ongemak 
 
Ik heb een beetje pijn of ongemak 
 
Ik heb matige pijn of ongemak 
 
Ik heb ernstige pijn of ongemak 
 
Ik heb extreme pijn of ongemak 
 
ANGST / DEPRESSIE 
 
Ik ben niet angstig of depressief 
 
Ik ben een beetje angstig of depressief 
 
Ik ben matig angstig of depressief 
 
Ik ben erg angstig of depressief 
 
Ik ben extreem angstig of depressief 
 
 
 
 


 
 
 
 
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 
We willen weten hoe goed of slecht uw gezondheid VANDAAG is. 
 
Deze meetschaal (te vergelijken met een thermometer) is genummerd van 0 
tot 100. 
 
100 staat voor de beste gezondheid die u zich kunt voorstellen. 
0 staat voor de slechtste gezondheid die u zich kunt voorstellen. 
 
Plaats een X op de meetschaal om aan te geven hoe uw gezondheid 
VANDAAG is. 
 
Noteer nu het getal dat u aangeduid hebt op de meetschaal in het 
onderstaande vakje. 
 
  
 
 
 
 
UW GEZONDHEID VANDAAG = 
10
0
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95


 
 
 
 
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18 APPENDIX 3 : EQ-5D QUESTIONNAIRE (FRENCH) 
 
Pour chaque rubrique, veuillez cocher UNE case, celle qui décrit le mieux votre santé AUJOURD’HUI. 
Mobilité 
 
Je n’ai aucun problème pour me déplacer à pied 
 
J’ai des problèmes légers pour me déplacer à pied 
 
J’ai des problèmes modérés pour me déplacer à pied 
 
J’ai des problèmes sévères pour me déplacer à pied 
 
Je suis incapable de me déplacer à pied 
 
Autonomie de la personne 
 
Je n’ai aucun problème pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes légers pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes modérés pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes sévères pour me laver ou m’habiller tout(e) seul(e) 
 
Je suis incapable de me laver ou de m’habiller tout(e) seul(e) 
 
Activités courantes (exemples: travail, études, travaux ménagers, activités 
familiales ou loisirs) 
 
Je n’ai aucun problème pour accomplir mes activités courantes 
 
J’ai des problèmes légers pour accomplir mes activités courantes 
 
J’ai des problèmes modérés pour accomplir mes activités courantes 
 
J’ai des problèmes sévères pour accomplir mes activités courantes 
 
Je suis incapable d’accomplir mes activités courantes 
 
Douleurs / gêne 
 
Je n’ai ni douleur ni gêne 
 
J’ai des douleurs ou une gêne légère(s) 
 
J’ai des douleurs ou une gêne modérée(s) 
 
J’ai des douleurs ou une gêne sévère(s) 
 
J’ai des douleurs ou une gêne extrême(s) 
 
Anxiété / Dépression 
 
Je ne suis ni anxieux(se), ni déprimé(e) 
 
Je suis légèrement anxieux(se) ou déprimé(e) 
 
Je suis modérément anxieux(se) ou déprimé(e) 
 
Je suis sévèrement anxieux(se) ou déprimé(e) 
 
Je suis extrêmement anxieux(se) ou déprimé(e) 
 
 
 
 
 


 
 
 
 
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 
Nous aimerions savoir dans quelle mesure votre santé est bonne ou 
mauvaise AUJOURD’HUI. 
 
Cette échelle est numérotée de 0 à 100. 
 
100 correspond à la meilleure santé que vous puissiez imaginer. 
0 correspond à la pire santé que vous puissiez imaginer. 
 
Veuillez faire une croix (X) sur l’échelle afin d’indiquer votre état de santé 
AUJOURD’HUI. 
 
Maintenant, veuillez noter dans la case ci-dessous le chiffre que vous avez 
coché sur l’échelle. 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VOTRE SANTÉ AUJOURD’HUI = 
10
0
20
30
40
50
60
80
70
90
100
5
15
25
35
45
55
75
65
85
95


 
 
 
 
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19 APPENDIX 4 : URINARY COLLECTION PROCEDURE 
Urinary collection procedure: 
Patients need to empty their bladder before the administration of the start dose of loop diuretics.  
The urinary collection need to start immediately after first bolus administration of loop diuretics and 
acetazolamide or placebo and the collection will stop the latest as close to but prior to the morning bolus 
of study medication on day 3. This collection will be defined as the Total Urinary Collection in the study. 
Importantly, the total volume needs to be written down in the study files as this is will be used for tertiary 
end-point analysis and is needed for the clinician to decide if escalation of therapy is needed. 
Total Urinary Collection equals the sum of Urinary Collection period 1 + Urinary Collection period 2: 
Urinary Collection period 1 = Urine collection that starts immediately after first bolus administration until 
the morning of day 2. This Urinary Output 1 value will be reported in the CRF together with start- and stop 
date/time of this first collection period.  
Urinary Collection period 2 = Urine collection that starts with the end of Urinary Output 1 until the morning 
of day 3 prior to the morning bolus of study medication. This Urinary Output 2 value will be reported in the 
CRF together with start- and stop date/time of this second collection period. 
How to collect the urine? 
Urinary catheter insertion is strongly recommended but not mandatory to achieve an optimal urine 
collection. However, in case of urinary incontinence, placement of a urinary catheter is mandatory.  
Alternatively, the patient need to use a urinary container(s) to collect ALL urine. Prior to the stop of urinary 
collection period the patient need to be instructed to empty their bladder. Care should be taken to ensure 
ALL urine is collected.   
At the end of a Urinary Collection period all urine of this period needs to be collected in the 
urinary container(s). 
Which measurements need to be done?  
For each urinary collection period the container(s) or a sample (if multiple containers are kept, they need 
to be mixed before taking a sample) will need to be sent to the local lab for analysis of the volume, Cr, 
total protein and Na (and bumetanide level, if available). 
 
 
 
 


 
 
 
 
 KCE Trials programme  
 Protocol KCE-17001 ADVOR, Version 1.0, 09 MAY 2018 
Page 74 of 74 
20 APPENDIX 5 : AMENDEMENT HISTORY  
Amendment 
No. 
Protocol 
version no. 
Date issued 
Author(s) of 
changes 
Details of changes made 
 
 
 
 
 
 
List details of all protocol amendments here whenever a new version of the protocol is produced. 
Protocol amendments must be submitted to the Sponsor for approval prior to submission to the EC 
committee or FAMHP. 
 
 


 
Final Protocol 
Version - 2.0 
3rd of January 2019 
 


 
 
 
 
 
 
FULL/LONG TITLE OF THE TRIAL 
A multi-center, randomized, double-blind, phase IV clinical trial on the diuretic effects of Acetazolamide 
(Diamox ®) in patients with Decompensated heart failure and Volume OveRload 
SHORT STUDY TITLE / ACRONYM 
Acetazolamide (Diamox ®) in Decompensated heart failure with Volume OveRload (ADVOR) 
PROTOCOL VERSION NUMBER AND DATE 
Version number: version 2.0 
Version date: 03 January, 2019 
 
RESEARCH REFERENCE NUMBERS 
EudraCT Number: 
2018-001345-14 
Clinical trials.gov 
Number: 
NCT03505788 
SPONSOR Number: 
ZOLCAR17001 
KCE Trial Number: 
KCE-17001  


 
 
 
 
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Page 2 of 75 
 TABLE OF CONTENTS 
1 
BACKGROUND .............................................................................................................. 16 
2 
RATIONALE .................................................................................................................... 17 
2.1 
ASSESSMENT AND MANAGEMENT OF RISK ............................................................................... 18 
3 
OBJECTIVES AND ENDPOINTS / OUTCOME MEASURES .......................................... 20 
3.1 
PRIMARY OBJECTIVE ..................................................................................................................... 20 
3.2 
SECONDARY OBJECTIVES ............................................................................................................ 20 
3.3 
ENDPOINTS ..................................................................................................................................... 20 
3.4 
PRIMARY ENDPOINT ...................................................................................................................... 21 
3.5 
SECONDARY ENDPOINTS ............................................................................................................. 21 
3.6 
EXPLORATORY TERTIARY ENDPOINTS ...................................................................................... 22 
4 
TRIAL DESIGN ............................................................................................................... 23 
5 
STUDY SETTING ............................................................................................................ 24 
6 
ELIGIBILITY CRITERIA .................................................................................................. 25 
6.1 
INCLUSION CRITERIA ..................................................................................................................... 25 
6.2 
EXCLUSION CRITERIA .................................................................................................................... 25 
7 
TRIAL PROCEDURES .................................................................................................... 27 
7.1 
RECRUITMENT ................................................................................................................................ 27 
7.1.1 
Patient identification ............................................................................................................ 27 
7.1.2 
Screening ............................................................................................................................ 27 
7.2 
CONSENT ......................................................................................................................................... 28 
7.3 
THE RANDOMISATION SCHEME ................................................................................................... 29 
7.4 
BLINDING ......................................................................................................................................... 29 
7.5 
UNBLINDING .................................................................................................................................... 29 
7.6 
SCREENING PHASE ASSESSMENTS ........................................................................................... 30 
7.7 
TREATMENT PHASE ASSESSMENTS ........................................................................................... 31 
7.7.1 
Day 1 ................................................................................................................................... 31 
7.7.2 
Day 2, Day 3 and Day 4 ...................................................................................................... 31 
7.8 
FOLLOW-UP PHASE ASSESSMENTS ........................................................................................... 32 
7.9 
TABLE OF TRIAL PROCEDURES ................................................................................................... 33 
7.10 
LABORATORY SUB-STUDY ............................................................................................................ 34 
7.11 
WITHDRAWAL CRITERIA ................................................................................................................ 35 
7.12 
END OF TRIAL.................................................................................................................................. 35 
8 
TRIAL INTERVENTION / MEDICATION ......................................................................... 36 
8.1 
NAME AND DESCRIPTION OF INTERVENTION(S) ....................................................................... 36 
8.2 
LEGAL STATUS OF THE INTERVENTION ..................................................................................... 41 
8.3 
SUMMARY OF PRODUCT CHARACTERISTICS (SMPC) .............................................................. 41 
8.4 
DRUG STORAGE AND SUPPLY ..................................................................................................... 41 
8.5 
PREPARATION AND LABELLING OF INVESTIGATIONAL MEDICINAL PRODUCT .................... 41 
8.6 
DOSAGE SCHEDULES .................................................................................................................... 42 
8.7 
DOSAGE MODIFICATIONS ............................................................................................................. 42 
8.8 
ASSESSMENT OF COMPLIANCE ................................................................................................... 42 
9 
SAFETY REPORTING .................................................................................................... 43 
9.1 
DEFINITIONS.................................................................................................................................... 43 


 
 
 
 
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9.2 
RECORDING AND REPORTING SAFETY INFORMATION ............................................................ 43 
9.3 
RESPONSIBILITIES ......................................................................................................................... 48 
9.4 
NOTIFICATION OF DEATHS ........................................................................................................... 49 
9.5 
REPORTING URGENT SAFETY MEASURES ................................................................................ 49 
9.6 
THE TYPE AND DURATION OF THE FOLLOW-UP OF SUBJECTS AFTER ADVERSE 
EVENTS ............................................................................................................................................ 49 
9.7 
DEVELOPMENT SAFETY UPDATE REPORTS .............................................................................. 49 
10 
STATISTICS AND DATA ANALYSIS .............................................................................. 50 
10.1 
SAMPLE SIZE CALCULATION ........................................................................................................ 50 
10.2 
PLANNED RECRUITMENT RATE ................................................................................................... 50 
10.3 
STATISTICAL ANALYSIS PLAN ...................................................................................................... 50 
10.4 
DATA COLLECTION FOR ECONOMIC EVALUATION ................................................................... 52 
11 
DATA HANDLING ........................................................................................................... 54 
11.1 
DATA COLLECTION TOOLS AND SOURCE DOCUMENT IDENTIFICATION .............................. 54 
11.2 
DATA HANDLING AND RECORD KEEPING ................................................................................... 55 
11.3 
ACCESS TO DATA ........................................................................................................................... 55 
11.4 
ARCHIVING ...................................................................................................................................... 55 
12 
MONITORING, AUDIT & INSPECTION ........................................................................... 56 
13 
ETHICAL AND REGULATORY CONSIDERATIONS ...................................................... 57 
13.1 
ETHICS COMMITTEE (EC) REVIEW & REPORTS ......................................................................... 57 
13.2 
PEER REVIEW ................................................................................................................................. 57 
13.3 
PUBLIC AND PATIENT INVOLVEMENT ......................................................................................... 57 
13.4 
REGULATORY COMPLIANCE ......................................................................................................... 58 
13.5 
PROTOCOL COMPLIANCE ............................................................................................................. 58 
13.6 
NOTIFICATION OF SERIOUS BREACHES TO GCP AND/OR THE PROTOCOL ......................... 59 
13.7 
DATA PROTECTION AND PATIENT CONFIDENTIALITY .............................................................. 59 
13.8 
FINANCIAL AND OTHER COMPETING INTERESTS FOR THE CHIEF INVESTIGATOR, PIS AT 
EACH SITE AND COMMITTEE MEMBERS FOR THE OVERALL TRIAL MANAGEMENT ............ 60 
13.9 
INDEMNITY ....................................................................................................................................... 60 
13.10 
ACCESS TO THE FINAL TRIAL DATASET ..................................................................................... 60 
14 
DISSEMINATION POLICY .............................................................................................. 61 
14.1 
DISSEMINATION POLICY ................................................................................................................ 61 
14.2 
AUTHORSHIP ELIGIBILITY GUIDELINES AND ANY INTENDED USE OF PROFESSIONAL 
WRITERS .......................................................................................................................................... 62 
15 
REFERENCES ................................................................................................................ 64 
16 
APPENDIX 1: AUTHORISATION OF PARTICIPATING SITES ...................................... 67 
17 
APPENDIX 2: EQ-5D QUESTIONNAIRE (DUTCH) ........................................................ 69 
18 
APPENDIX 3 : EQ-5D QUESTIONNAIRE (FRENCH) ..................................................... 71 
19 
APPENDIX 4 : URINARY COLLECTION PROCEDURE ................................................. 73 
20 
APPENDIX 5 : CONCOMITANT MEDICATION .............................................................. 74 
21 
APPENDIX 6 : AMENDMENT HISTORY ......................................................................... 75 
 






 
 
 
 
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KEY TRIAL CONTACTS 
 
Chief Investigator 
Wilfried Mullens MD, PhD self-employed operating at 
Department of Cardiology, Ziekenhuis Oost-Limburg, Autonome Verzorgingsinstelling 
Schiepse Bos 6, 3600 Genk, Belgium 
E-mail: 
    
Phone: 
   
Trial Coordinator 
Katrien Tartaglia 
Clinical Trial Unit, Ziekenhuis Oost-Limburg, Autonome Verzorgingsinstelling 
Schiepse Bos 6, 3600 Genk, Belgium 
E-mail: 
 
Phone 
  
Sponsor 
Ziekenhuis Oost Limburg Autonome Verzorgingsinstelling  
Schiepse bos 6, 3600 Genk, Belgium 
Main contact person:  Evi Theunissen  
Phone: 
  / E-mail: 
 
Legal contact persons:  Joke Vanlangenaeker and Martine Verplancke 
Phone: 
 / E-mail:   
 
Although KCE provides funding for the trial, KCE shall under no circumstances be 
considered as sponsor of the Study or assume any responsibilities or liabilities in 
connection therewith, and sponsor or co-sponsor shall make no representations 
whatsoever in this respect. 
Funder(s) 
Belgian Health Care Knowledge Centre (KCE) 
Administrative Centre Botanique, Doorbuilding, Boulevard du Jardin Botanique 55, B-
1000 Brussels, Belgium  
E-mail. 
  
 
Clinical Trial Unit 
Ziekenhuis Oost Limburg Autonome Verzorgingsinstelling  
CTU ZOL  
E-mail: 
 
Project team  
ADVOR study team 
Clinical Trial Unit, Ziekenhuis Oost-Limburg, Autonome Verzorgingsinstelling 




 
 
 
 
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TRIAL SUMMARY 
Trial Title  
A multi-center, randomized, double-blind, phase IV clinical trial on the 
diuretic effects of Acetazolamide (Diamox ®) in patients with 
Decompensated heart failure and Volume OveRload 
Short title 
Acetazolamide (Diamox ®) in Decompensated heart failure with Volume 
OveRload 
Clinical Phase 
IV 
Study type 
Interventional 
Planned sample size 
Approximately 519 patients  
Trial duration 
Approximately 27 months (3 months follow-up / patient) 
Planned Trial Period 
2018-2021 
Purpose and rationale 
To investigate if combination therapy with acetazolamide improves loop 
diuretic efficacy to increase diuresis in decompensated heart failure (HF) 
patients, allowing for a better/faster decongestion and potentially 
resulting in improved clinical outcome and increased quality of life. 
Primary endpoint 
Treatment success (decongestion achieved) on the morning of day 4 
without the need for escalating diuretic strategy (doubling loop diuretic 
dose, addition of chlorthalidone, or ultrafiltration) on the morning of day 
3  
Secondary endpoints 
1. Combined end-point of all-cause mortality and heart failure 
readmission during 3 months of follow-up 
2. Length of index hospital admission 
3. Longitudinal changes in EuroQoL five dimensions questionnaire 
(EQ-5D) (baseline, the morning of day 4 or at discharge 
(whatever comes first), any readmission, and 3 months). 
Trial Design 
The ADVOR study is a phase IV randomized, multi-center, double-blind 
study, comparing monotherapy with high-dose loop diuretics (standard 
of care - SOC) versus combination therapy with acetazolamide and high-
dose loop diuretics in patients with decompensated heart failure and 
clinical signs of volume overload.  
The study consists of 3 phases: 
 
screening phase: starting from identifying a study subject prior 
to / during hospitalization until the first dose of study medication 
will be given 
 
treatment phase: starting from the first dose of study medication 
administration until the morning of day 4 or earlier in case of 
successful decongestion sooner. 
 
follow-up phase: starting when the treatment phase ends until 3 
months after the study start dose. 
Trial Participants 
The study population will consist of patients hospitalized with 
decompensated HF and demonstrating at least one clinical sign of 
volume overload. 
Main Inclusion Criteria 
 
An elective or emergency hospital admission with clinical diagnosis 
of ADHF and at least one clinical sign of volume overload (e.g. 
oedema, ascites or pleural effusion) 
 Maintenance therapy with oral loop diuretics at a dose of at least 
1 mg bumetanide or 40 mg furosemide or 20 mg torsemide for at 
least 1 month before hospital admission  
 Plasma NT-proBNP levels >1000 ng/L or BNP levels >250 ng/L at 
screening 
 


 
 
 
 
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Main Exclusion Criteria 
 
Concurrent diagnosis of an acute coronary syndrome defined as 
typical chest pain in addition to a troponin rise above the 99th 
percentile and electrocardiographic changes suggestive of cardiac 
ischemia 
 History of congenital heart disease requiring surgical correction 
 History of cardiac transplantation and/or ventricular assist device 
 Systolic blood pressure <90 mmHg or mean arterial pressure 
<65 mmHg at screening 
 Expected 
use 
of 
intravenous 
inotropes, 
vasopressors 
or 
nitroprusside during the study. Use of nitrates and/or molsidomine is 
allowed at the discretion of the treating physician 
 Estimated glomerular filtration rate (eGFR) <20 mL/min/1.73m² at  
screening 
 Use of renal replacement therapy or ultrafiltration at any time before 
study inclusion 
 Treatment with intravenous loop diuretics > 2 mg bumetanide or an 
equivalence of another loop diuretic during the index hospitalization 
before randomization 
 Treatment with acetazolamide within 1 month prior to randomization 
 Exposure to nephrotoxic agents (i.e. contrast dye) anticipated within 
the next 3 days 
 Use of any non-protocol defined diuretic agent with the exception of 
mineralocorticoid receptor antagonists during the treatment phase of 
the study. Thiazides, metolazone, indapamide and amiloride should 
be stopped upon study inclusion. If patient is taking a combination 
drug including a thiazide-type diuretic, the thiazide-type diuretic 
should be stopped upon study inclusion. 
 Current use of sodium-glucose transporter-2 inhibitors 
 Subjects who are pregnant or breastfeeding  
 Subjects with urinary incontinence who are not willing to receive a 
bladder catheter 
Exploratory tertiary end-
points 
 Body weight change after day 1, 2, 3, 4 and discharge compared to 
screening 
 All-cause mortality during first 3 months after study start dose 
 Heart failure readmissions during first 3 months after study start dose 
 All cause rehospitalisations during first 3 months after study start 
dose 
 Total urinary volume and natriuresis starting from first intravenous 
(IV) diuretic administration at randomization until the morning of day 
3 (urinary output, see figure 1 and appendix 4) 
 Relative plasma BNP or NT-proBNP change from screening until the 
assessment on day 4 or at discharge (whatever comes first) and at 3 
months 
 Total dose of IV loop diuretics used during treatment phase.  
 Changes in doses of neurohumoral blockers from baseline to 
discharge and after 3 months 
 Need for renal replacement therapy or ultrafiltration during first 3 
months after study start dose 
 Incidence of hyponatremia during treatment phase 
 Hypokalaemia during treatment phase 
 Incidence of metabolic acidosis requiring NaHCO3 supplements 
during first 4 days 
 WRF defined as a >0.3 mg/dL increase in serum Cr, or a >20% 
decrease in eGFR by the CKD-EPI formula during treatment phase 
 Liver dysfunction at screening 
 Plasma volume changes during treatment phase (assessed by 
albumin and hematocrit) 
 Occurrence of iron deficiency at screening 


 
 
 
 
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Optional laboratory sub-study in participating centers: 
 Change from baseline in selected biomarkers from baseline through 
3 months after study start dose in a subset of randomized patients 
Safety assessments 
 
Adverse events 
 
Laboratory values (including monitoring hypokalaemia, metabolic 
acidosis, substantial increase in creatinine (Cr), substantial decrease 
in eGFR) 
Data analysis 
 
The treatment effect for the primary endpoint is evaluated by means 
of a generalized linear mixed model. The statistical model will include 
a fixed treatment effect and random center effect. 
 
For the first secondary end-point [occurrence of the combined 
endpoint of all-cause mortality and heart failure re-admission during 
3 months of follow-up], a generalized linear mixed model for a binary 
outcome will be used. The model will incorporate a fixed treatment 
effect and random center effect. If the treatment effect on the 
composite endpoint of ‘all-cause mortality and HF readmission’ turns 
out to be statistically significant, both components will be evaluated 
separately in a hierarchical fashion with HF readmissions first and 
all-cause mortality second. 
 
Length of index hospitalization and change in quality of life scores 
are compared among treatment arms with a linear mixed model 
(fixed treatment effect and random center effect). Transformation will 
be employed when the model assumptions (such normality) are 
violated.  
 
All hypothesis are 2-sided and tested with a significance level of  
α=0.05 
 
 
 
 
 


 
 
 
 
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ROLE OF STUDY SPONSOR AND FUNDER 
Ziekenhuis Oost Limburg autonome verzorginsinstelling (ZOL AV), as mentioned in KEY TRIAL CONTACT 
shall act as sponsor of the Study, as defined in the Law of 2004, and in accordance with the Law of 2004, 
the sponsor shall assume, even without fault, the responsibility of any damage incurred by a study patient 
or, in the case of death, his rightful claimants sustained that arises either in direct or indirect connection 
with the experiments and shall provide compensation therefore. The Sponsor shall enter into an insurance 
contract in accordance with article 29 of the Law of 2004. ZOL AV shall ensure that it shall be mentioned 
in the Protocol, the Informed Consent Forms and in other relevant communication with the Study Subjects 
or the Regulatory Authorities as sponsor of the Study.  
ZOL AV has designed the trial together with the Trial Steering Committee (TSC). ZOL AV and the TSC will 
be responsible for the data analysis (with assistance of the “center of statistics”, University Hasselt), 
interpretation, manuscript writing, and dissemination of results. ZOL AV will have the final decision 
regarding any of these aspects of the trial. However, publication of the main study results will be the 
responsibility of the TSC. Even in case of a negative study result, the data will be published. 
ZOL AV acknowledges and agrees for the avoidance of doubt that KCE shall under no circumstances be 
considered as sponsor of the Study or assume any responsibilities or liabilities in connection therewith, and 
ZOL AV shall make no representations whatsoever in this respect.  
 
 


 
 
 
 
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ROLES AND RESPONSIBILITIES OF TRIAL MANAGEMENT 
COMMITEES 
Trial Steering Committee (TSC) 
The role of the Trial Steering Committee (TSC) is to provide the overall supervision of the trial. The TSC 
includes members who are independent of the investigators, their employing organisations or institutions, 
funders and sponsors. The TSC monitors trial progress, conduct and advise on scientific credibility. The 
TSC will consider and act, as appropriate, and ultimately carries the responsibility for deciding whether a 
trial needs to be stopped on grounds of safety or efficacy. The TSC shall oversee the performance of the 
study and discuss important topics in relation thereto.  
The TSC will meet on average 3 times per year or as necessary when adapted to the stage of the trial (set-
up, conduct, analysis). The TSC is composed of the CI, trial statistician, the trial coordinator, 7 independent 
experts, minimum 2 representatives of other participating centers with at least one representative of the 
French speaking sites and one representative of the Dutch speaking sites, up to 2 representatives of 
patients or the general public, 1 representative of the sponsor and 1 representative of the funder. The TSC 
will send reports to the sponsor and the funder. KCE shall have the right (but not the obligation) to be 
present at each TSC meeting. 
Details of the final members of the TSC, their responsibilities, number of meetings and reporting procedures 
can be found in the TSC charter.  
Trial Management Group (TMG) 
The TMG includes those individuals responsible for the day-to-day management of the trial, such as the 
Chief Investigator, statistician, trial coordinator, and data manager. The role of the group is to monitor all 
aspects of the conduct and progress of the trial, ensure that the protocol is adhered to and take appropriate 
action to safeguard participants and the quality of the trial itself.  
Chief Investigator: Wilfried Mullens (ZOL AV, Genk, Belgium) 
Statistician: Liesbeth Bruckers (University Hasselt, Belgium)    
Trial Coordinator: Katrien Tartaglia (ZOL AV, Genk, Belgium)   
Data Manager: Liesbet Van Brussel (ZOL AV, Genk, Belgium)   
Data Safety Monitoring Committee (DSMC)  
The DSMC is not needed as this is a low-risk pragmatic interventional trial with a short inclusion period 
studying an old drug with a well-known safety profile within an accepted clinical indication. 
Endpoint Adjudication Committee (EAC)  
The EAC will adjudicate the HF-related endpoints. Throughout the course of the study the EAC will assess 
events, and determine whether these events should contribute to the secondary endpoints of the ADVOR 
trial. HF readmissions are defined as either a hospital admission because of decompensated HF or an 
unscheduled contact at the emergency department for worsening HF if the patient is treated with 


 
 
 
 
 KCE Trials programme                 Protocol KCE-17001 ADVOR, Version 2.0, 03 JAN 2019 
Page 13 of 75 
intravenous loop diuretics. The EAC will have at least two members, specialized in heart failure 
management. None of the EAC members will be participating investigators in the ADVOR trial. 
LIST OF ABBREVIATIONS 
 
 
ADHF 
Acute Decompensated Heart Failure 
AE 
Adverse Event 
BID 
“Bis in die” (twice a day) 
BWGHF 
Belgian Working Group of Heart Failure 
BNP 
B-type natriuretic peptide 
CI 
Chief Investigator 
Cr 
Creatinine 
EAC 
Endpoint Adjudication Committee 
eCRF 
Electronic Case Report Form 
EF 
Ejection fraction 
eGFR 
Estimated glomerular filtration rate  
EQ-5D 
EuroQol five dimension (questionnaire) 
ESC 
European society of Cardiology 
GCP 
Good Clinical Practice 
GMP 
Good Manufacture Practice 
HFA 
Heart Failure Association 
HF 
Heart Failure 
HFpEF 
Heart Failure with preserved Ejection Fraction 
HFrEF 
Heart Failure with reduced Ejection Fraction 
HTA 
Health technology assessment 
IEC 
Independent ethics committee 
IMP 
Investigational medicinal product 
IRT 
Interactive response technology 
ISF 
Investigator Site File 
IV 
Intravenous 
NT-proBNP 
N-terminal of pro-B-type natriuretic peptide 
MG 
milligram 
PI 
Principal Investigator 
PM 
Project Manager 
QoL 
Question of Life 
RCT 
Randomised Clinical Trial 
RRT 
Renal replacement therapy 
SD 
Source document 
SI 
Sub-investigator 
SOC 
Standard of care 
TMG 
Trial Management Group 
TSC 
Trial Steering Committee 


 
 
 
 
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VAS 
Visual analogue scale 
WRF 
Worsening renal function 
ZOL AV 
Ziekenhuis Oost Limburg Autonome Verzorgingsinstelling 
 
 
 


 
 
 
 
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TRIAL FLOW CHART 
Figure 1. Trial flow Chart. 
 


 
 
 
 
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1 BACKGROUND 
Aging of the population and prolongation of the lifespan of cardiac patients by modern therapeutic 
innovations have led to an increased incidence of HF (1). During the last two decades, important progress 
has been made in the treatment of ambulatory HFrEF patients. Renin-angiotensin system blockers, 
β-blockers, mineralocorticoid receptor antagonists, ivabradine, neprilysin inhibition, and cardiac 
resynchronization therapy have all been demonstrated to reduce morbidity and/or mortality in ambulatory 
HFrEF patients (2-18).  
Despite these important advances, many patients are still hospitalized frequently with decompensated HF 
demonstrating most often signs and symptoms of systemic congestion and volume overload, which is 
associated with worse outcome (19). Treatment in these cases mainly focuses on symptomatic relief 
through administration of diuretics, although clear evidence on the optimal agent, dosing schedule, and 
administration route is lacking. Coexisting renal dysfunction often complicates decongestive treatment and 
worsening renal function (WRF), often defined as a 0.3 mg/dL rise in serum Cr, is a common finding in this 
context (20). However, the prognostic impact of WRF defined as Cr change is unsure as it might be 
associated with worse, neutral or even better outcome (21-23). In contrast, persistent congestion and 
volume overload, as a reflection of the renal inability to preserve sodium homeostasis, has been more 
consistently associated with higher mortality and more frequent readmissions in HF (24). This suggests 
that achieving a net negative fluid balance might be an attractive treatment target in decompensated HF. 
Loop diuretics are by far the most commonly used agents to achieve decongestion in decompensated HF. 
Especially in diuretic-naïve patients, they are often very effective to relief dyspnoea and congestive 
symptoms. However, in the Diuretic Optimization Strategies Evaluation (DOSE) trial, which is the only 
randomized clinical trial on diuretic therapy for decompensated HF patients, no differences in patients’ 
global assessment of symptoms or change in renal function were observed when loop diuretics were 
administered by bolus as compared with continuous infusion or at high versus low dose during a 
hospitalization for decompensated HF (25). Also, only a minority of patients (15%) were adequately 
decongested after 72 h in the DOSE trial, thereby indicating the urgent need for more effective decongestive 
therapies. Furthermore, guidelines from international cardiac societies lack high-quality data on the optimal 
dosing, timing and method of delivery of diuretic agents. Importantly, there are several reasons why loop 
diuretics might be less effective or even harmful in HF. First, loop diuretics directly stimulate renin 
production by inhibiting the Na+/K+/2Cl--cotransporter on the luminal side of the macula densa, which 
depletes intracellular chloride levels in the macula densa. The consequence is an increased cyclo-
oxygenase-2 and nitric oxide synthase I activity in macula densa cells, leading to paracrine prostaglandin 
E2 and nitric oxide secretion (26). Both prostaglandin E2 and nitric oxide work in concert to stimulate renin 
release by granulosa cells of the afferent arteriole and further detrimental activation of the 
renin-angiotensin-aldosterone axis. Second, impaired secretion of loop diuretics in the proximal tubules of 
HF patients, especially when there is concomitant renal dysfunction, results in lower concentrations at the 
place where these agents act – the luminal side of the thick ascending limb of Henle’s loop. Third, increased 
sodium reabsorption in the proximal tubules might result in less sodium offered to the thick ascending limb 


 
 
 
 
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of Henle’s loop, especially if glomerular filtration is concomitantly impaired, hampering the efficacy of loop 
diuretics. 
Recent advances in heart failure (HF) biomarker studies suggest promise from markers enhancing 
traditional method of assessing affected patients. B-type natriuretic peptide (BNP) and its biologically inert, 
amino-terminal pro-peptide counterpart (NT-proBNP)32,33 have quickly become an essential component in 
the diagnosis and determining prognosis in HF. With a large number of biomarkers now or soon to be 
available, an understanding of the role that biomarkers may play in HF care is necessary. 
2 RATIONALE  
From a pathophysiological point of view, targeting sodium reabsorption in the proximal tubules has several 
potential benefits in HF. First, it is the place where most sodium is reabsorbed, especially in decompensated 
HF. Second, greater delivery of chloride to macula densa cells decreases renin production, ceasing 
neurohumoral activation. Third, endogenous natriuretic peptides (acting in the distal nephron) will possibly 
regain their effects (27). The carbonic anhydrase inhibitor acetazolamide (Diamox®), which is approved for 
the treatment of mountain sickness, inhibits sodium reabsorption in the proximal tubules. Despite the 
pathophysiological rationale for inhibition of proximal sodium reabsorption in decompensated HF, 
acetazolamide is now a largely forgotten diuretic. One observational study in patients with decompensated 
HF and marked volume overload found that the addition of acetazolamide improved loop diuretic efficacy 
with ~100 mmol Na+ excreted per 40 mg of furosemide equivalent dose (28). Thus, although the diuretic 
and natriuretic capacity of acetazolamide is poor on its own, it might well be a very efficient booster of 
diuretic efficacy in combinational diuretic therapy with loop diuretics. This concept is further supported by 
one small randomized trial including 24 patients with volume overload refractory to loop diuretic therapy 
(29). All these patients demonstrated a greatly reduced fractional sodium excretion, which was easily 
overcome by the addition of acetazolamide. We’ve conducted a small two-center trial to see if improved 
diuretic efficacy with acetazolamide in a patient population with heart failure and cardio-renal syndrome at 
high risk for diuretic resistance translates into better natriuresis. (Clinical Trial NCT01973335). The study 
has just been finished with analysis of the results ongoing. Importantly, the promising concept of blocking 
proximal nephron sodium absorption with acetazolamide has been published over the last couple of years 
(30). 
The ADVOR study has an innovative primary end-point. As abundant evidence has consistently linked 
persistent volume overload after decongestive therapy in decompensated HF with poor outcomes, 
decongestion itself is a valid surrogate end-point (24). It has been demonstrated from reanalysis of the 
DOSE trial and CARRESS that the persistent oedema has excellent prognostic ability to predict death, 
readmissions or unscheduled medical contacts (31). In ADVOR, a more exhaustive congestion score with 
the emphasis on relief of volume overload will be used. Secondary end-points in ADVOR will be very 
clinically relevant. A more thorough decongestion should also translate into less readmissions for recurrent 
decompensation, better renal preservation, and eventually lower mortality. This will be assessed as a key 
secondary end-point after hospital stay. Additionally, time to decongestion is a major determinant of hospital 
stay and combinational therapy with acetazolamide might significantly shorten this. Finally, improved quality 


 
 
 
 
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of life for patients is expected with better decongestion and will be the last secondary end-point. Importantly, 
acetazolamide is an easy and cheap drug to use (add on, bolus infusion, no special monitoring required), 
with a potentially favourable cost-efficiency profile. Important health economic data, specifically for the 
Belgian situation, will be obtained through the ADVOR study.  
During the ADVOR study centers can decide to participate in the optional laboratory sub-study. The urine 
and blood samples collected through this laboratory sub-study will be stored in the University Biobank of 
Limburg and it will become the biggest databank of its kind within diuretic studies for patients with 
decompensated heart failure.  
This laboratory sub-study will investigate more in detail the mechanistic and potential favourable effect of 
acetazolamide and loop diuretics. Furthermore, this laboratory sub-study will provide new insights into the 
pathophysiology of decompensated HF and potentially will allow for identifying a high risk patient 
population. This could ultimately lead to improved and patient tailored treatment strategies. Biomarker sub-
studies have become a valuable source of data for such analysis, and offer unique insights into mechanistic 
and pathophysiologic pathways in a well selected and phenotyped patient population.   
 
2.1 Assessment and management of risk 
The study will examine if the addition of acetazolamide will lead to a better decongestion in decompensated 
HF patients with volume overload. It’s expected that the better decongestion will lead to less HF 
readmissions, reduced all-cause mortality, improved quality of life, reduced hospital stay duration and 
significant reduction in HF related health care expenditure.  
The ADVOR trial will investigate if adding acetazolamide, which can be very easily administered, in every 
hospital, without additional extra testing or invasive monitoring, through a bolus infusion in acute 
decompensated heart failure (ADHF) patients might lead to faster, safer and easier decongestion. If proven 
beneficial, this approach can easily be adopted by every hospital in a quick manner with considerable cost-
savings with regards to health care expenditure and improvements of quality of life for patients. 
Importantly, ADVOR will examine if an improved application of existing decongestive therapies (not novel 
drugs), based on strong scientific reasoning, will result in a better outcome for patients and society. 
Therefore, data from the study will provide information regarding the safety and efficacy of acetazolamide 
treatment in above mentioned patient population.  
As such, the ADVOR study was specifically designed to have maximum benefit without additional risk for 
this frail patient population. The study will: 
1) Be conducted with limited additional testing 
2) Have minimal or no additional expected risk for the patient (comparison of standard diuretic 
regimen with standard diuretic regimen + addition of acetazolamide) 
3) Have very clinically meaningful endpoints. Achieving a faster decongestion with reduced risk for 
escalation of therapy, which often increases complication rates as well as length of hospital stay. 


 
 
 
 
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This will be beneficial for the patients in the short-term. Additionally, a more thorough decongestion 
should also translate into less readmissions for recurrent decompensation and improved quality of 
care 
Therefore, ADVOR can be considered a ‘Low-intervention clinical trial’ as: 
1) Acetazolamide, the investigational medicinal products, which already has been authorised, has a 
very low risk profile and is well-known to the general cardiologist 
2) According to the protocol of the clinical trial, Acetazolamide the investigational medicinal product, 
will be used in accordance with the terms of the marketing authorisation  
3) The additional diagnostic or monitoring procedures do not pose more than minimal additional risk 
or burden to the safety of the subjects compared to normal clinical practice 
 


 
 
 
 
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3 
OBJECTIVES AND ENDPOINTS / OUTCOME MEASURES  
ADVOR will investigate if combination therapy with acetazolamide improves loop diuretic efficacy to 
increase diuresis in decompensated HF patients with volume overload, allowing for a better/faster 
decongestion and a lower total dose of loop diuretics. A better / faster decongestion should lead to less HF 
readmission, reduced all-cause mortality, shorter length of stay and improved quality of life. 
3.1 Primary objective 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy 
with high-dose loop diuretics (standard of care - SOC) versus combination therapy with acetazolamide and 
high-dose loop diuretics in patients with decompensated HF and clinical sign(s) of volume overload. While 
the SOC results in 15% effective decongestion, it’s estimated - based on strong scientific reasons - that the 
combination therapy should have a success rate of 25%, which represents a clear meaningful benefit of 
10% more patients with appropriate decongestion after 72 h.  
- 
Population; patients hospitalized with decompensated HF and demonstrating signs of volume overload. 
- 
Intervention: combination therapy with high-dose loop diuretics + acetazolamide 
- 
Comparison: monotherapy with high-dose loop diuretics + placebo 
- 
Outcome: % decongestion, need for escalating diuretic therapy, HF readmission, all-cause mortality, 
length of stay, QoL 
- 
Time: 72 h for primary endpoint, 3 months for secondary endpoint 
3.2 Secondary objectives 
1. Combination therapy with acetazolamide improves loop diuretic efficacy to increase diuresis in 
decompensated HF patients, allowing for a better/faster decongestion and a lower total dose of 
loop diuretics. 
2. Combination therapy with acetazolamide leads to lower occurrence of diuretic resistance and 
escalating diuretic therapy in decompensated HF 
3. Combination therapy with acetazolamide will potentially lead to improved clinical outcome in 
decompensated HF (less heart failure readmissions, lower all-cause mortality)  
4. Combination therapy with acetazolamide will shorten the length of stay in patients with 
decompensated HF, which is expected to reduce health care expenditure 
5. Combination therapy with acetazolamide will potentially lead to improved quality of life 
3.3 Endpoints  
The ADVOR study has an innovative primary end-point. As abundant evidence has consistently linked 
persistent volume overload after decongestive therapy in decompensated HF with poor outcomes, 
decongestion itself is a valid surrogate end-point. It has been demonstrated from reanalysis of the DOSE 
trial and CARRESS that the persistent oedema has excellent prognostic ability to predict death, 
readmissions or unscheduled medical contacts. In ADVOR, a more exhaustive yet easy to use – ‘volume 


 
 
 
 
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assessment’ score - will be used. Importantly, ADVOR will be a double blind randomized trial thereby 
excluding any potential for bias in the clinical judgement of the treating physician for any of the endpoints 
including the primary endpoint of decongestion.  
Secondary endpoints in ADVOR will be very clinically relevant. A more thorough decongestion should also 
translate into less readmissions for recurrent decompensation, and eventually lower mortality. This will be 
assessed as a key secondary end-point after hospital stay. Additionally, time to decongestion is a major 
determinant of hospital stay and combinational therapy with acetazolamide might significantly shorten this. 
Finally, improved quality of life for patients is expected with better decongestion and will be the last 
secondary endpoint. Importantly, acetazolamide is an easy drug and very cheap drug to use (add on, bolus 
infusion, no special monitoring required), which will therefore be easily adopted by the health care. 
Endpoints have also been discussed with “Mon Coeur Entre Parenthèses” which is a HF patient association 
(VZW) representing HF patients and their peers and deemed to be important by them. 
In addition, the primary and secondary outcome measures are in line with the COMET (Core Outcome 
Measures in Effectiveness Trials) initiative. Indeed ‘decongestion’ (being dry is for the patient a very 
important improvement in symptomatology), heart failure readmission, all-cause mortality, length of stay 
and quality of life can all be considered standardised relevant core outcomes sets. Therefore, the core 
outcomes relevant for any acute heart failure study will be collected and reported, making it easier for the 
results of ADVOR to be compared, contrasted and combined as appropriate with other trials (Zannad F et 
al, European Journal of Heart Failure, 2013;15:1082-1094). Additionally, we will continue to explore other 
tertiary outcomes, which are often mechanistically very interesting, as well. 
We will also collect the dosages of neurohumoral blocker therapy throughout the study period, thereby 
hopefully facilitating a better implementation of guideline recommended therapy. As guidelines recommend 
a specific dosage for each of these drugs in HFrEF, it’s easy to standardize the intake of such medications 
to be used in an accurate analysis. This will be done as an exploratory tertiary end-point. 
3.4 Primary endpoint 
Treatment success (decongestion achieved) on the morning of day 4 without the need for escalating diuretic 
strategy (doubling loop diuretic dose, addition of chlorthalidone, or ultrafiltration) on the morning of day 3.  
3.5 Secondary endpoints  
1. Combined end-point of all-cause mortality and heart failure readmission during 3 months of follow-
up 
2. Length of index hospital admission 
3. Longitudinal changes in EuroQoL five dimensions questionnaire (EQ-5D) (as soon as possible after 
screening up to day 1, the morning of day 4 or at discharge (whatever comes first), at any 
readmission, 3 months) 


 
 
 
 
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3.6 Exploratory tertiary endpoints   
1. Body weight change after day 1, 2, 3, 4 and discharge compared to screening   
2. All-cause mortality during first 3 months after study start dose 
3. Heart failure readmissions during first 3 months after study start dose 
4. All cause rehospitalisation during first 3 months after study start dose 
5. Total urinary volume and natriuresis starting from first intravenous (IV) diuretic administration at 
randomization until the morning of day 3  
6. Relative plasma BNP or NT-proBNP change from screening until day 4 or at discharge (whatever 
comes first) and at 3 months follow up visit 
7. Total dose of IV loop diuretics used during first 4 days 
8. Changes in doses of neurohumoral blockers from baseline to discharge and after 3 months. 
9. Need for renal replacement therapy or ultrafiltration during first 3 months after study start dose 
10. Hyponatremia during treatment phase 
11. Hypokalaemia during treatment phase 
12. Incidence of metabolic acidosis requiring NaHCO3 supplements during first 4 days 
13. WRF defined as a >0.3 mg/dL increase in serum Cr, or a >20% decrease in eGFR by the CKD-EPI 
formula during treatment phase 
14. Liver dysfunction at screening 
15. plasma volume changes during treatment phase (assessed by albumin and hematocrit) 
16. Occurrence of iron deficiency at screening 
17. Optional laboratory sub-study in participating centers: Change from screening in selected 
biomarkers from baseline through 3 months after study start dose in a subset of randomized 
patients 
 
 


 
 
 
 
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4 TRIAL DESIGN 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy of 
high-dose loop diuretics (SOC) versus combination therapy of acetazolamide with high-dose loop diuretics 
in patients with decompensated HF and volume overload. Data from the study will provide information 
regarding the safety and efficacy of acetazolamide treatment in the above-mentioned patient population. 
Randomized clinical trial with 2 treatment arms; therapy with high-dose loop diuretics and placebo vs 
therapy with high-dose loop diuretics and acetazolamide. An automated web-based system is used to 
randomly assign patients in a 1:1 ratio with variable blocks sizes, stratified for LVEF according to study 
center. To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the population 
will be stratified at inclusion according to LVEF ≤40% versus >40%. Permuted block randomisation, at 
center and LVEF stratum level will be used to achieve this. Objective is to demonstrate superiority of the 
combination therapy with regards to achieving decongestion at 72 hours.  
The study consists of 3 phases (cfr Figure 1 Flow Chart): 
 
screening phase: starting from identifying a study subject prior / during hospitalization until the first 
dose of study medication will be given  
 
treatment phase: starting from the first dose of study medication administration until the morning of 
day 4 or earlier in case of successful decongestion sooner 
 
follow up phase: starting when the treatment phase ends until 3 months after the study start dose 
 
 


 
 
 
 
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5 STUDY SETTING 
The study population will consist of patients hospitalized for decompensated HF with clinical sign(s) of 
volume overload. The goal is to randomize approximately 519 patients in approximately 24 centers in 
Belgium. Importantly, participating centers are located in Flanders, Wallonia and Brussels, which also 
ensures that the study population is representative of the real-life patient population in which the study drug 
will be used in case the study is positive.  
The study is supported by the members of the Belgian Working Group of Heart Failure (BWGHF). This is 
a national scientific non-profit group which was established in 2004 as one of the official working groups of 
the Belgian Society of Cardiology. Therefore, a positive result will almost immediately be adopted by the 
Belgian cardiology community as all members of the BWGHF are considered leaders in the field.  
Finally, only centers who have fulfilled all the duties with regards to study selection and training will be 
allowed to randomize patients. 
 
 


 
 
 
 
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6 ELIGIBILITY CRITERIA 
Decompensated HF patients with volume overload independent of ejection fraction might be included. This 
is important as 50% of decompensated HF patients are HFpEF patients (HF with preserved ejection 
fraction) and 50% of the decompensated HF patients are HFrEF patients (HF with reduced ejection 
fraction). In addition, patients do not need to have an echocardiogram at study inclusion to establish left 
ventricular ejection fraction which further simplifies the inclusion procedure. Finally, the DOSE trial (only 
other RCT studying the effects of diuretic therapy) also included patients without pre-specification of EF. 
To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the population will be 
stratified at inclusion according to LVEF ≤40% versus >40% (assessed within 12 months before inclusion). 
Permuted block randomisation according to center and LVEF stratum will be used to achieve this.  
Importantly, though the diagnosis of HF sometimes is difficult to establish in HFpEF, the main inclusion 
criteria are; 1) clinical diagnosis of decompensated HF and at least one clinical sign of volume overload 
(e.g. oedema, ascites or pleural effusion), 2) increased BNP / NT-ProBNP to ensure the volume overload 
is secondary to congestion/heart failure and 3) maintenance therapy with oral loop diuretics at a dose of ≥ 
1 mg bumetanide or equivalent dose for ≥ 1 month before hospital admission will be remained. The 
combination of these three criteria will guarantee that only decompensated HF patients with volume 
overload will be included.  
6.1 Inclusion criteria 
 
Signed written informed consent must be obtained before any study assessment is performed 
 
Male or female patients of 18 years of age or older 
 
An elective or emergency hospital admission with clinical diagnosis of decompensated HF with at 
least one clinical sign of volume overload (e.g. oedema (score 2 or more), ascites confirmed by 
echography or pleural effusion confirmed by chest X-ray or echography) 
 
Maintenance therapy with oral loop diuretics at a dose of at least 1 mg bumetanide or an equivalent 
dose for at least 1 month before hospital admission (Conversion: 1 mg bumetanide = 
40 mg furosemide = 20 mg torsemide) 
 
Plasma NT-proBNP levels >1000 ng/L or BNP levels >250 ng/L at the time of screening. 
 
Assessed LVEF by any imaging technique; i.e. echocardiography, catheterization, nuclear scan or 
magnetic resonance imaging within 12 months of inclusion 
6.2 Exclusion criteria 
 
Concurrent diagnosis of an acute coronary syndrome defined as typical chest pain in addition to a 
troponin rise above the 99th percentile and electrocardiographic changes suggestive of cardiac 
ischemia 
 
History of congenital heart disease requiring surgical correction 
 
History of a cardiac transplantation and/or ventricular assist device 
 
Systolic blood pressure <90 mmHg or mean arterial pressure <65 mmHg at screening 


 
 
 
 
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 
Expected use of intravenous inotropes, vasopressors or nitroprusside during the study. The use of 
nitrates and/or molsidomine is allowed at the discretion of the treating physician. 
 
Estimated glomerular filtration rate <20 mL/min/1.73m² at screening 
 
Use of renal replacement therapy or ultrafiltration at any time before study inclusion 
 
Treatment with intravenous loop diuretics > 2 mg bumetanide or an equivalence of another loop 
diuretic during the index hospitalization and prior to randomization 
 
Treatment with acetazolamide within 1 month prior to randomization 
 
Exposure to nephrotoxic agents (i.e. contrast dye) anticipated within the next 3 days 
 
Use of any non-protocol defined diuretic agent with the exception of mineralocorticoid receptor 
antagonists during the treatment phase of the study.. Thiazides, metolazone, indapamide and 
amiloride should be stopped upon study inclusion. If patient is taking a combination drug including 
a thiazide-type diuretic, the thiazide-type diuretic should be stopped. 
 
Current use of sodium-glucose transporter-2 inhibitors 
 
Subjects who are pregnant or breastfeeding  
 
Subjects with urinary incontinence who are not willing to receive a bladder catheter. 
 
 


 
 
 
 
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7 TRIAL PROCEDURES  
7.1 Recruitment 
Patients might be enrolled during an admission of decompensated HF with volume overload, on the 
condition of fulfilling inclusion and not fulfilling exclusion criteria. In addition, patients might already be 
informed that they could participate in the study during an outpatient visit (if they need to be hospitalized 
for decompensated HF). Patients will be recruited by the sites within a period of approximately 24 months.  
7.1.1 Patient identification 
It is recommended to inform the medical team (cardiology and the health care providers) who might have 
first contact with potential study subjects (e.g. emergency room physicians) about the trial. They should 
inform the subject regarding the trial. Only a member of the patient’s existing clinical care team should have 
access to patients’ records without explicit consent in order to identify potential participants and check 
whether they meet the inclusion criteria or make the initial approach to patients. In case the treating 
physician is not a member of the ADVOR trial (a principal investigator (PI) or sub-investigator (SI)), he/she 
could refer the patient to the ADVOR investigator. The screening process can start only if a written informed 
consent is obtained. The investigator of the ADVOR trial should confirm eligibility of the subject. 
Potential participants might also be recruited through publicity (posters, leaflets) which can be made 
publically available in cardiology outpatient departments only if approval has been obtained by the ethics 
committee. 
7.1.2 Screening 
Following screening technical requirements are necessary to meet any noted inclusion or exclusion criteria: 
 
laboratory tests (BNP or NT-proBNP part of inclusion criteria and eGFR part of exclusion criteria) 
 
chest X ray or chest ultrasound in case pleural effusion is used as inclusion criteria. Importantly, 
a chest X-ray is considered standard of care in case of decompensated HF (guidelines of the 
European Society of Cardiology (ESC))  
 
abdominal ultrasound in case ascites is used as inclusion criteria 
No other technical procedure need to be performed as part of routine care. However, the LVEF assessed 
by any technical exam (echocardiogram, nuclear scan, MRI, catheterization) within the last 12 months will 
need to be recorded. As only patients already treated with a loop diuretic are allowed in the study, we 
expect that every patient has a LVEF recorded within 12 months preceding study entry.  
We don’t expect screen failures i.e. patients who do not meet eligibility criteria at time of screening are not 
able to enter the study at a later stage as we expect them to have received already more than 2 mg loop 
diuretics intravenously (which will count as an exclusion criterium). 


 
 
 
 
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Patients will not receive any special incentives or compensation through participation in the study. No 
specific study visits are needed. The 3 month FU visit is standard of care as recommended by the guidelines 
of the ESC. Study related exams (BNP or NT-proBNP) will be reimbursed by the study. 
7.2 Consent  
The Principal Investigator (PI) retains overall responsibility for the informed consent of participants at their 
site and must ensure that any person delegated responsibility to participate in the informed consent process 
is duly authorised, trained and competent to participate according to the ethically approved protocol, 
principles of Good Clinical Practice (GCP) and Declaration of Helsinki. If delegation of consent is acceptable 
then details should be provided. 
Informed consent must be obtained prior to the participant undergoing procedures that are specifically for 
the purposes of the trial and are outside of standard routine care at the participating site (including the 
collection of identifiable participant). In case the patient agrees to participate in the optional laboratory sub-
study, an additional signed and dated informed consent must be obtained before the laboratory sub-study 
blood and urine samples will be collected.  
The right of a participant to refuse participation without giving reasons must be respected.   
The participant must remain free to withdraw at any time from the trial without giving reasons and without 
prejudicing his/her further treatment and will be provided with a contact point where he/she may obtain 
further information about the trial. Where a participant is required to re-consent or new information is 
required to be provided to a participant it is the responsibility of the PI to ensure this is done in a timely 
manner.  
The PI takes responsibility for ensuring that all vulnerable patients are protected and participate voluntarily 
in an environment free from coercion or undue influence. 
Eligible patients may only be included in the study after providing written (witnessed, where required by law 
or regulation), Independent Ethics Committee (IEC) approved informed consent or if patient is incapable of 
doing so, after such consent has been provided by a legally acceptable representative(s) of the patient. In 
cases the patient’s representative gives consent, the patient should be informed about the study to the 
extent possible given his/her understanding. If the patient is capable of doing so, he/she should indicate 
assent by personally signing and dating the written informed consent document.  
The process of obtaining informed consent should be documented in the patient source documents. 
Once the informed consent has been signed by the patient and patient is randomised, a new patient file 
should be created in the electronic Case Report Form (eCRF) by the PI or the qualified person to whom 
this task has been delegated. Once the patient file is created, the eCRF system will automatically generate 
a trial number for this patient. Once a number is assigned to a patient, the patient number can’t be re-used.  


 
 
 
 
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7.3 The randomisation scheme 
Randomized clinical trial with 2 treatment arms; therapy with high-dose loop diuretics and placebo vs 
therapy with high-dose loop diuretics and acetazolamide. An automated web-based system is used to 
randomly assign patients in a 1:1 ratio with variable blocks sizes, stratified for LVEF according to study 
center. To ensure an equal proportion of HFpEF versus HFrEF patients in both study arms, the population 
will be stratified at inclusion according to LVEF ≤40% versus >40%. Permuted block randomization 
according to center and LVEF stratum will be used to achieve this.  
Only the PI or qualified person to whom he/she has delegated this study task can randomize the patient in 
the automated web-based system. 
7.4 Blinding 
This is a double-blind study. Therefore, after randomization, the study team and patient will not be aware 
of which treatment (acetazolamide or placebo) is administrated to the trial participant.  
Once a patient is assigned to a study group (treatment group or control group), he/she will remain in that 
arm and all efforts will be made to provide the optimal therapy specified for that treatment assignment. In 
the unforeseen circumstance that this is clinically not feasible, the patient will remain in the assigned 
treatment arm for statistical analysis based on the intention-to-treat principle, as it represents a normal 
medical situation of success and failure of delivering the planned medical therapy. 
7.5 Unblinding 
Patient, site personnel, sponsor personnel and data analysts will remain blinded to the identity of the 
treatment from the time of randomization until database lock. Though we do not foresee serious adverse 
events related to the study drug, the study code should only be broken for valid medical or safety reasons 
e.g. in the case of a severe adverse event where it is necessary for the investigator or treating health care 
professional to know which treatment the patient is receiving before the participant can be treated. It is not 
mandatory but strongly encouraged to contact the chief investigator before unblinding any patients’ 
treatment assignment. Patient and members of the research team should remain blinded. 
Following rules apply for unblinding; 
 
Rapid unblinding of a patient can be performed by a physician of the study team. Detailed 
information concerning the unblinding procedures is provided in the Manual of Operations.  
 
On receipt of the treatment allocation details, the PI or treating health care professional will 
continue to deal with the participant’s medical emergency as appropriate. 
 
The PI/Investigation team documents the breaking of the code and the reasons for doing so on 
the medical notes and eCRF. It will also be documented at the end of the trial in any final study 
report and/or statistical report. 


 
 
 
 
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Unblinded data are to be kept strictly confidential until the time of unblinding of the trial and will not be 
accessible by anyone else involved in the trial with the following exceptions: (1) the PM of the company 
responsible for the labelling and packaging of the IMP, (2) the IRT system programmers who work on the 
randomization and drug management system; and (3) the data manager who prepares reports required for 
regulatory reporting (suspected unexpected serious adverse reactions [SUSAR] reporting). These 
individuals will not be involved in the day-to-day running of the study. 
7.6 Screening phase assessments 
Screening testing will occur after the consent process has been finalized. The screening data gathering 
needs to be performed prior to the administration of the study diuretic agents. The following assessments 
are required and data need to be collected:  
 
Obtain written informed consent 
 
Check inclusion and exclusion criteria 
 
Collect demographics (collect age, gender, race and ethnicity) 
 
Collect medical history and notification of LVEF 
 
Collect concomitant medication (see Appendix 5) 
 
Collect vital signs including body weight, arterial blood pressure and heart rate 
 
EQ-5D patient questionnaire to be completed by the patient (Appendix 2 and 3) 
 
Perform volume assessment by the Principal Investigator or a Sub-investigator who has been 
trained in the study volume assessment. Volume assessment is based on the presence of oedema, 
ascites, pleural effusion (Figure 3 in section 8). 
 
Collect blood sample for local laboratory assessment: serum hemoglobin, hematocrit, electrolytes 
(Na, K, Cl, HCO3), serum osmolality, serum urea, serum Cr, total protein, serum albumin, Fe, 
ferritin, TSAT, LDH, troponin, eGFR and plasma BNP or NT-proBNP  
o 
In a subset of randomized patients participating in the laboratory sub-study blood collected 
during screening will be shipped to the University Biobank Limburg (see section 7.10) 
 
Perform pregnancy urine test (applicable for all pre- menopausal women who are not surgically 
sterile) 
 
Randomization (see section 7.3) 
 
 


 
 
 
 
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7.7 Treatment phase assessments 
7.7.1 Day 1 
 
Request patient to empty their bladder before administration of the first dose of loop diuretics. 
 
Administer the first bolus of loop diuretics and acetazolamide or placebo to the patient.  
 
Start the urinary collection immediately after first bolus of loop diuretics and acetazolamide or 
placebo is administered. The collection will stop the latest as close to but prior to the morning bolus 
of study medication on day 3. Urinary catheter insertion is strongly recommended but not 
mandatory to achieve an optimal urine collection. However, in case of urinary incontinence, 
placement of a urinary catheter is mandatory. Care should be taken to ensure ALL urine is 
collected. For more details regarding the study urinary collection see appendix 4. 
If the patient is enrolled between midnight and 6 a.m., day 1 assessments and day 2 assessment can 
be performed on the same day but only if there is a difference of minimum 6 hours between the start of 
the study medication on day 1 and study medication on day 2.  
7.7.2 Day 2, Day 3 and Day 4 
 
Collect vital signs including body weight, arterial blood pressure, heart rate 
 
As long as patient is assessed as volume overloaded during the previous volume assessment, 
perform volume assessment by the Principal Investigator or a Sub-investigator who has been 
trained in the study volume assessment (Figure 3 in section 8) 
 
Collect morning blood sample for local laboratory assessment: serum haemoglobin, haematocrit, 
electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr, serum albumin.  
 
On the morning of Day 2 and Day 3, collect an urine sample from urine collection period 1 and 
period 2 respectively for analysis in local lab. In case patient is participating in the optional 
laboratory sub-study, collect an additional urine sample for each urine collection period for 
shipment to the University Biobank Limburg for storage and additional research (see section 7.10). 
Urinary collection will stop at the morning of day 3 (appendix 4). 
 
In case patient is still volume overloaded continue study treatment as described in section 8 
 
Collect concomitant medication (see Appendix 5) 
 
Document and assess adverse events (section 9) 
 
In addition, on the morning of day 4 or at discharge (whatever comes first):  
o 
EQ-5D to be completed by the patient.  
o 
Collect blood sample for local laboratory assessment of the BNP or NT-ProBNP level. In a 
subset of randomized patients participating in the laboratory sub-study blood collected on day 
4 will be shipped to the University Biobank Limburg (see section 7.10) 
 


 
 
 
 
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7.8 Follow-up phase assessments 
 
At Discharge: 
o 
Perform volume assessment by the Principal Investigator or a Sub-investigator who has been 
trained in the study volume assessment (Figure 3 in section 8)  
o 
Collect weight  
o 
Collect concomitant medication (see Appendix 5) 
o 
Document length of hospitalization 
o 
Document and assess adverse events (section 9) 
 
 
At Readmission: 
o 
HF readmissions are defined as either a hospital admission because of decompensated HF or 
an unscheduled contact at the emergency department if the patient is treated with intravenous 
loop diuretics. 
o 
During any readmission, EQ-5D questionnaire needs to be completed by the patient as soon 
as possible during the admission 
 
 
Long term follow-up 
Patients will be followed for a maximum of three months for secondary/tertiary endpoint analysis. 
This follow-up should not differ from standard of care for such patients. During one outpatient 
follow-up appointment 3 months (90 days) (+ 14 days) after the start of study medication, standard 
of care data will be collected. The only study related tests will be a BNP / NT-ProBNP test and the 
collection of the EQ-5D patient questionnaire. 
During this follow –up visit the following data will need to be collected: 
o 
Collect vital signs including body weight, arterial blood pressure, heart rate 
o 
EQ-5D patient questionnaire to be completed by the patient (Appendix 2 and 3) 
o 
Perform volume assessment by Principal Investigator or Sub-investigator  who has been 
trained in the study volume assessment (Figure 3 in section 8) 
o 
Collect blood sample for local laboratory assessment: serum hemoglobin, hematocrit, 
electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr, serum albumin, and plasma BNP or NT-
proBNP. In a subset of randomized patients participating in the laboratory sub-study blood 
collected on this visit will be shipped to the University Biobank Limburg (see section 7.10) 
o 
Collect concomitant medication (see Appendix 5) 
o 
Document and assess adverse events (section 9) 
We do not foresee that a significant amount of patients will be lost to follow-up as the follow-up period 
is short (max 3 months). The investigator should make every effort to contact participants who are 
lost to follow-up. Attempts to contact such participants must be documented in the participant’s 
records. 


 
 
 
 
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7.9 
Table of trial procedures 
 
Screening 
phase 
Treatment phase 
Follow up phase 
 
 
 
Study 
Day 1 
Morning 
of Study 
Day 2 
Morning 
of Study 
Day 3 
Morning 
of Study 
Day 415 
Discharge 
Re-
admission 
3 Months 
after study 
start dose 
Informed consent 
X 
 
 
 
 
 
 
 
In- and exclusion 
criteria 
X 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
Demographics1 
X 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
Vitals2 
X 
 
X 
X 
X 
 
 
X 
Weight12 
X 
 
X 
X 
X 
X 
 
X 
EQ5D 
X 
 
 
 
X 
 
X11 
X 
Volume 
assessment 
X 
 
X16 
X16 
X16 
X 
 
X 
Study treatment 
 
X3 
X4 
X4 
 
 
 
 
Urinary 
collection5 
X 
X 
X 
 
 
 
Local lab 
X6 
 
X7 
X7 
X7 
 
 
X7 
Laboratory sub-
study13 blood 
X 
 
 
 
X14 
 
 
X 
Laboratory sub-
study13 Urine 
 
 
X 
X 
 
 
 
 
Plasma BNP or 
NT-proBNP8 
X 
 
 
 
X 
 
 
X 
Urine pregnancy 
testing9 
X 
 
 
 
 
 
 
 
Concomitant 
medication17 
X  
X 
X 
X 
X 
X 
 
X 
Adverse Events10  
X 
X 
X 
X 
X 
X 
X 
X 
1) 
Age, race and ethnicity 
2) 
Arterial blood pressure and heart rate 
3) 
Start dose (IV) = 2 x orally daily maintenance dose of loop diuretics and 500 mg acetazolamide or placebo (see section 8) 
4) 
As long as patient is volume overloaded, Treatment dose (IV) = 1x orally daily maintenance dose of loop diuretics and 500 
mg acetazolamide or placebo between 8:00 and 12:00 and a second dose minimum 6 hours later with again 1x orally 
daily maintenance dose (see section 8) 
5) 
See appendix 4 
6) 
Serum hemoglobin, hematocrit, electrolytes (Na, K, Cl, HCO3), serum osmolality, serum urea, serum Cr, total protein, 
serum albumin, Fe, ferritin, TSAT, LDH, troponin and eGFR 
7) 
Serum hemoglobin, hematocrit, electrolytes (Na, K, Cl, HCO3), serum urea, serum Cr and serum albumin 


 
 
 
 
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8) 
Protocol requires that plasma levels of BNP or NT-proBNP are collected. In case the patient is on succubutril/valsartan, it 
is mandatory that NT-proBNP plasma levels are determined on the blood sample. 
9) 
Only pre- menopausal women who are not surgically sterile, as well as women of childbearing potential. 
10) Safety reporting flow is documented in section 9 
11) EQ5-D needs to be collected once during any readmission (as soon as poss ble during readmission)) 
12) Measurement of body weight should be performed as consistently as poss ble using a standardized scale, preferably with 
a precision of 50 g, in the morning, post-void, prior to eating, prior to the medication dose, and with patients wearing the 
same clothing. The scales should stand on a flat, solid surface rather than carpets unless specifically designed for use in 
that setting 
13) Blood and urine will be collected in a subset of randomized patients participating in the laboratory sub-study. Blood will be 
collected on screening, day 4 or at discharge (whatever comes first) and 3 month FU visit. Urine sample will be collected 
from Urinary Collection period 1 and Urinary collection period 2 (see also appendix 4). 
14) In case day 4 falls into a weekend or public holiday, blood collection for sub-study can also be done on day 5 or day 6. If a 
patient is being discharged before the morning of day 4, blood collection for the sub-study should occur at discharge. 
15) In case discharge is earlier than the morning of day 4, all assessments of day 4 should be performed at discharge. 
16) As long as patient was assessed volume overloaded during the previous volume assessment a volume assessment needs 
to be performed 
17) See appendix 5 
 
7.10 Laboratory sub-study 
Blood samples and urine samples from centers who agreed to participate in the Laboratory sub-study will 
be collected during the Advor trial. All potential patients at these centers will be asked to participate in the 
laboratory sub-study. An additional signed and dated informed consent must be obtained before the 
additional blood and urine samples will be collected.  
The right of a participant to refuse participation without giving reasons must be respected. The participant 
must remain free to withdraw at any time from this sub-study without giving reason and without prejudicing 
his/her further treatment and will be provided with a contact point where he/she may obtain further 
information about the sub-study. Where a participant is required to re-consent or new information is required 
to be provided to a participant it is the responsibility of the PI to ensure this is done in a timely manner. 
All patients enrolled in the laboratory sub-study will have blood collected on screening, day 4 and during 
the 3 month follow up visit. In case the patient is being discharged before the morning of day 4, blood 
samples should be collected at discharge. The collected blood samples will be shipped to the University 
Biobank Limburg for storage and additional research. Urine samples collected from the Urinary Collection 
period 1 and from the Urinary Collection period 2 (see appendix 4) will be shipped to the University Biobank 
Limburg for storage and additional research. 
Biomarkers related to cardiac and renal function/injury will be obtained from blood and urine in the subset 
of patients participating in the laboratory sub-study. Biomarkers will be used to elucidate the effect of 
acetazolamide and to explore drug effect versus baseline biomarkers of risk. Biomarkers of potential 
interest are NT-proBNP, Galectin 3, ST2, Cystatin C and NGAL. The list of potential biomarkers may be 
changed or expand further as it is recognized that more relevant or novel biomarkers may be discovered. 
Biomarkers may be measured during the process of this study or after its completion. No genetic analysis 
will be performed with the collected sub-study samples. Detailed sample handling instructions will be 
provided in a separate laboratory manual.  
 


 
 
 
 
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7.11 Withdrawal criteria  
All subjects will be encouraged to remain on treatment and under observation for the full duration of the 
study. However, at any time during the study and without giving reasons, subjects may withdraw from the 
study at their own request or at the request of their legally acceptable representative. The subject will not 
suffer any disadvantage as a result.  
It is important to note that discontinuation of study treatment (see section 8) is not the equivalent to 
withdrawal of informed consent. In cases where subjects indicate they do not want to "continue", 
investigators must determine whether this refers to discontinuation of study treatment (the most common 
expected scenario), unwillingness to attend the follow-up visit, unwillingness to have telephone contact, 
unwillingness to have any contact with study personnel, or unwillingness to allow contact with a third party 
(e.g., family member, doctor). Every effort must be made to continue to follow the subject until the end of 
the study. 
In all cases, the reason for discontinuation (including "at the subject's request") must be recorded in the 
case report form (CRF) and in the subject's medical records. 
No subject replacements are permitted in the study. 
7.12 End of trial 
The Sponsor’s CTU ZOL will notify the FAMHP and main EC of the end of a clinical trial within 90 days of 
its completion date (last patient last visit).  
 


 
 
 
 
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8 TRIAL INTERVENTION / MEDICATION 
The ADVOR study is a phase IV randomized, multi-center, double-blind study, comparing monotherapy 
with high-dose loop diuretics and placebo (standard of care - SOC) versus combination therapy with 
acetazolamide and high-dose loop diuretics in patients with decompensated heart failure and clinical signs 
of volume overload.  
8.1 Name and description of intervention(s) 
At randomization 
At the moment of randomization, oral loop diuretics are stopped and the patient receives an IV bolus of 
loop diuretics at a dose equal to the double of his oral daily maintenance dose* with a maximal dose of 5 
mg bumetanide (=200 mg furosemide). Bumetanide is the preferred loop diuretic agent to be used in this 
trial. 
Conversion factor:  
1 mg bumetanide po = 1 mg bumetanide IV 
40 mg furosemide po = 40 mg furosemide IV 
20 mg torsemide po = 40 mg furosemide IV = 1 mg bumetanide IV 
Some examples are listed below: 
- 
if a patient takes 1x1 mg bumetanide po, the patient will receive 2x1x1 mg = 2 mg bumetanide IV 
- 
if a patient takes 2x2,5 mg bumetanide po, the patient will receive 2x2x2,5 mg = 5 mg bumetanide IV 
- 
if a patient takes 1x40 mg furosemide po, the patient will receive 2x1x40 mg = 80 mg furosemide IV 
- 
If a patient takes 1x80 mg furosemide po, the patient will receive 2x1x80 mg = 160 mg furosemide IV 
- 
If a patient takes 1x20 mg torsemide po, the patient will receive 2x1x1 mg bumetanide IV = 2 mg 
bumetanide IV or 2x1x40 furosemide IV = 80 mg furosemide IV 
Together with this initial dose of loop diuretics patients will receive an intravenous bolus of 500 mg of 
acetazolamide or placebo. 
START DOSE (IV) = 2 x orally daily maintenance dose* of loop diuretics (max. 5 mg of 
bumetanide) 
+ 
500 mg acetazolamide or placebo 
*If the oral daily maintenance dose has changed over the week prior to randomization, it will be defined as 
the highest orally administered daily dose that the patient has received in an outpatient context 3 days prior 
to randomization. 
 
 


 
 
 
 
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During the treatment phase 
Between administering the start dose and next treatment dose a minimum of 6 hours is required. During 
the remaining part of the treatment phase, the patient will continue to receive 2 treatment doses every day 
provided that the treating physician has concluded during the morning rounds that the patient is still volume 
overloaded (see Figures 2+3). The dose will be the orally daily maintenance dose, administered between 
8:00 and 12:00 am, together with an intravenous bolus of 500 mg of acetazolamide or placebo. The second 
dose of loop diuretics, again the orally daily maintenance dose, will be given 6 hours after the morning 
dose.  
Any patient with more than trace oedema, residual pleural effusion or residual ascites would be considered 
to be still volume overloaded (see Figures 2 + 3). Residual pleural effusion and/or ascites should always 
be confirmed by chest X-ray or echography. If pleural effusion/ascites is used as an inclusion criteria, chest 
X-ray and/or echography should be repeated until decongestion has been achieved (volume assessment 
score ≤ 1). If not present at inclusion, new evidence of pleural effusion and/or ascites may arise during the 
treatment phase, but if scored, it should be confirmed by a chest X-ray or echography. If the patient is not 
volume overloaded anymore, the intravenous administration of study medication should be stopped. Once 
decongestion is achieved (volume assessment score ≤ 1) during the treatment phase, no volume 
assessment should be performed the following morning. 
 
Between 8:00 and 12:00 am TREATMENT DOSE (IV) = 1x orally daily maintenance dose 
(max. 5 mg of bumetanide) 
+  
500 mg acetazolamide or placebo 
 
6 hours later TREATMENT DOSE (IV) = 1x orally daily maintenance dose  
 
Figure 2. Flow chart to guide study. 
 
 


 
 
 
 
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After treatment phase  
After the treatment phase, treating physicians are recommended not to prescribe oral acetazolamide as a 
maintenance diuretic therapy after decongestion; instead, they are encouraged to restart the original oral 
maintenance dose of loop diuretics when the patient was still stable. Patients can be discharged as early 
as 24 hours after the physician concluded that the volume overload is no longer present. An outpatient 
follow-up appointment is scheduled at least 3 months (90 days) (with a window of + 14 days) after the start 
of study medication. It is mandatory to perform a volume assessment at discharge and at follow-up. It is 
recommended to perform a chest X-ray or echography in case of clinical signs of pleural effusion or ascites, 
yet, it will be left to the discretion of the treating physician. 
STOP TREATMENT 
The treating physician is allowed (but not obliged) to stop the study treatment, which counts as treatment 
failure in case of persistent volume-overload in following cases: 
- 
symptomatic hypotension with a systolic blood pressure <100 mmHg 
- 
asymptomatic hypotension with a systolic blood pressure <90 mmHg 
- 
an increase of serum Cr levels x 1.5 of the serum Cr level compared to admission value. 
- 
Occurrence of metabolic acidosis (ph < 7.2) 
If any of these events occur when the patient is judged to be euvolemic, the study treatment is stopped and 
stopping is not considered a treatment failure.  
Freedom from volume-overload (i.e. congestion) on the morning of day 4 will be defined as not more 
than trace oedema, no residual pleural effusion, and no residual ascites (Figure 3) 
 


 
 
 
 
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Figure 3: Volume assessment  
 
Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response  
If the total urinary output (see Figure 1 and Appendix 4) on the morning of day 3 is < 3500 mL and the 
patient is still volume overloaded, an escalation of decongestive treatment is mandatory. One of the outlined 
three options can be chosen at the discretion of the treating physician. 
Escalation therapy options: 
 
doubling of the IV dose of the loop diuretics  
 
add oral chlorthalidone 50 mg once daily 
 
ultrafiltration or renal replacement therapy might be considered 
The decision to proceed with escalation therapy needs to be collected in the case report form as the patient 
needing escalation cannot reach the primary endpoint. 
Background therapy  
24h oral intake of fluid and sodium will be restricted to 1500 mL and 1.5 g, respectively. It is recommended 
that all patients receive the same maintenance infusion with 500 mL glucose 5% and 3g MgSO4 
administered over 24h time interval, until complete decongestion or end of the study treatment phase. All 
non-protocol fluids administered (including those for administration of intravenous medication) should be 
limited.  
In case of serum potassium levels <4 mmol/L, 40 mmol of KCI is added to the maintenance infusion. 
Oral potassium supplements may be used at the discretion of the treating physician, but their use will be 
prospectively registered. 


 
 
 
 
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In case of metabolic acidosis with serum bicarbonate levels <20 mmol/L, it is recommended to administer 
intravenously 100 ml of NaHCO3 8.4%. 
Treatment with neurohumoral blockers (e.g. renin-angiotensin system blockers, sacubitril/valsartan, beta-
blockers, and mineralocorticoid receptor antagonists) may be continued at the same or lower dosage at the 
discretion of the treating physician, until the end of the treatment phase (max 4 days) or until complete 
decongestion is achieved, whatever comes first. Dose increases for any of these medications are not 
allowed during the screening and treatment phase with the exception of mineralocorticoid receptor 
antagonists in case of hypokalaemia despite intravenous potassium supplement. In addition, starting an 
SGLT2 inhibitor and a switch from renin-angiotensin system blockers to sacubitril/valsartan is not allowed 
during the screening and treatment phase, but might be pursued after decongestion is achieved. After 
decongestion, it is strongly recommended to up-titrate doses of neurohumoral blockers according to the 
guidelines in the HFrEF patients. Dosages of neurohumoral blockers are collected at screening, at 
discharge and at three months follow-up.  
 
 


 
 
 
 
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8.2 Legal status of the intervention  
The IMP (acetazolamide) is licensed for use in Belgium for the treatment of HF.  
 
8.3 Summary of Product Characteristics (SmPC) 
Information about common side effects already known about the investigational drug can be found in the 
SmPC filed in the Investigator Site File (ISF).  
SmPC in Dutch:  
http://bijsluiters.fagg-afmps.be/registrationSearchServlet?key=BE004137&leafletType=skp 
SmPC in French: 
http://bijsluiters.fagg-afmps.be/registrationSearchServlet?key=BE004137&leafletType=rcp 
8.4 Drug storage and supply  
The investigational medical product (IMP) (acetazolamide and placebo) will be shipped free of charge to 
the participating centers. The IMP must be received by a designated person in the pharmacy at the study 
center, handled and stored safely and properly, and kept in a secured location to which only the investigator 
and designees have access. Upon receipt, the PI or qualified delegated person will confirm the date of 
receipt of IMP. Receipt, distribution, return and destruction (if applicable) of the study drug must be properly 
documented according to the agreed and specified procedures. Specific instructions for the study drug 
recordkeeping are provided in the Manual of Operations. 
All IMP should be stored according to the instructions specified on the labels (room temperature below 
25°C).  
8.5 Preparation and labelling of Investigational Medicinal Product 
The IMPs (acetazolamide and placebo) will be presented as a white to off-white 500 mg powder for solution 
for injection in a sterile vial. Each study center will be supplied with study medication kits containing 3 vials 
of acetazolamide or placebo. Each kit will have an unique study kit number. The study medication supply 
will have appropriate labelled packaging according to national law of Good Manufacture Practices (GMP) 
ruling.  
Each IMP need to be reconstituted prior to use. Specific instructions will be provided in the Manual of 
Operations. The reconstituted solution is clear and colourless and does not contain an antimicrobial 
preservative. Any unused solution can be stored in a refrigerator for up to 24 hours but any solution not 
used within this period must be discarded. 
The direct intravenous route of administration is preferred. Intramuscular injection may be employed but is 
painful due to the alkaline pH of the solution. (preparation according to the SmPC see section 8.3) 


 
 
 
 
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8.6 Dosage schedules 
Cfr point 8.1 for specific dosage schedules and routes of administration. 
 
8.7 Dosage modifications  
Dosage modifications of the study drug are not possible as there will only be one dose (and the 
administration of the IMP vs placebo is blinded).  
8.8 Assessment of compliance 
As the study drug will be administered intravenously during the treatment phase by the nurse taking care 
of the patient, no compliance issues with regards to the study medication are foreseen.  
 
 


 
 
 
 
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9 SAFETY REPORTING 
As this is a pragmatic trial, the intervention will be used within the label and therefore safety reporting can 
be limited to the safety reporting which is necessary in routine care. 
Timely, accurate, and complete reporting of clinical events is of crucial importance for success of the study. 
Additionally, reporting and review of safety information for clinical studies are crucial for the protection of 
subjects.  
9.1 Definitions 
Term 
Definition 
Adverse Event (AE) 
Any untoward medical occurrence in a participant to whom a 
medicinal product has been administered, including occurrences 
which are not necessarily caused by or related to that product. 
Serious Adverse Event 
(SAE) 
A serious adverse event is any untoward medical occurrence that: 
 results in death 
 is life-threatening 
 requires inpatient hospitalisation or prolongation of existing 
hospitalisation 
 results in persistent or significant disability/incapacity 
 consists of a congenital anomaly or birth defect 
Other ‘important medical events’ may also be considered serious if 
they jeopardise the participant or require an intervention to prevent 
one of the above consequences. 
NOTE: The term "life-threatening" in the definition of "serious" refers 
to an event in which the participant was at risk of death at the time of 
the event; it does not refer to an event which hypothetically might 
have caused death if it were more severe. 
Suspected 
Unexpected Serious 
Adverse Reaction 
(SUSAR) 
A serious adverse reaction, the nature and severity of which is not 
consistent with the information about the medicinal product in 
question set out: 
 in the case of a product with a marketing authorisation, in the 
summary of product characteristics (SmPC) for that product 
 in the case of any other investigational medicinal product, in the 
investigator’s brochure (IB) relating to the trial in question 
 
9.2 Recording and reporting Safety Information 
During the course of this study, i.e. from signing the informed consent onwards until the end of the last 
follow-up visit, all SAEs, Endpoint Events and certain non-serious AEs which occurred until 3 months after 
study start dose are to be collected, documented, and reported by the Investigator in the applicable eCRF’s 
following below “safety reporting flow chart”: 
 
 


 
 
 
 
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Figure 4: Safety reporting flow chart 
 
How to assess Safety Events (AEs, SAEs and SUSARs) 
Seriousness, severity and causality need to be assessed by the Principal Investigator or the physician to 
whom this activity is delegated to.  
 
An adverse event is defined as a serious adverse event if the event is any untoward medical 
occurrence that at any dose: 
 
Results in death 
 
Is life-threatening 
 
Requires inpatient hospitalization or prolongation of existing hospitalization 
 
Results in persistent or significant disability/incapacity 
 
Is a congenital anomaly/birth defect, or 
 
Is an important medical event. 
Note: The term “life-threatening” in the definition of serious refers to an event in which the subject was at 
risk of death at the time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe  
The following definitions should be used to assess intensity of adverse events: 


 
 
 
 
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 
Mild: Awareness of sign or symptom, but easily tolerated, i.e. does not interfere with subject’s 
usual function. 
 
Moderate: Discomfort enough to cause interference with usual activity. 
 
Severe: Incapacitating with inability to work or do usual activity, i.e. interferes significantly with 
subject’s usual function. 
Severity vs. Seriousness: Severity is used to describe the intensity of a specific event whereas the event 
itself, however, may be of relatively minor medical significance (such as severe headache). This is not the 
same as "seriousness," which is based on subject/event outcome at the time of the event. 
The Investigator should assess causal relationship between an adverse event and the study drug on 
the basis of his/her clinical judgment, the latest SmPC (see section 8.3) and the following 
definitions. The causality assessment must be made based on the available information and can be 
updated as new information becomes available. 
Related: 
The AE follows a reasonable temporal sequence from study drug administration, and cannot be 
reasonably explained by the subject’s clinical state or other factors (e.g. disease under study, 
concurrent diseases, and concomitant medications). 
or 
The AE follows a reasonable temporal sequence from study drug administration, and is a known 
reaction to the drug under study or its chemical group, or is predicted by known pharmacology. 
Not Related: 
The AE does not follow a reasonable sequence from study drug administration, or can be 
reasonably explained by the subject’s clinical state or other factors (e.g. disease under study, 
concurrent diseases, and concomitant medications). 
 
Recording and reporting non-serious Adverse Events (AEs) 
AEs may be directly observed, reported spontaneously by the subject or by questioning the subject at each 
study visit. The Investigator must assess these AEs to determine seriousness, severity, and causality, in 
accordance with below definitions. The Investigator’s assessment must be clearly documented in the site’s 
source documentation. For the purposes of this study non-serious AEs that are related to the IMP or 
non-serious AEs that that occur in the cardiovascular system or non-serious AEs events involving 
imbalance of serum electrolytes (restricted to K+, Na+, HCO3) will be collected in the eCRF 
throughout the study. 
 
 


 
 
 
 
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Recording and reporting of SAEs AND SUSARs  
All SAEs an SUSARs will be collected throughout the study duration. Reporting of these events to the 
sponsor will  occur on the eCRF AE page.   
Reporting of SAEs and SUSARs is mandatory and should start; 
- 
For SAEs, from consent 
- 
For SUSARs, from 1st IMP dose 
If the SAE is unexpected, i.e., the event is not previously documented as ‘expected’, and is thought to be 
related to the study drug, this event is considered a Suspected Unexpected Serious Adverse Reaction 
(SUSAR).  
Where a participant withdraws consent for further processing of data, this does not preclude the reporting 
of SAEs and SUSARs which are required to continue being reported according to the protocol for regulatory 
purposes.  
In all cases SAEs should be reported to the Sponsor in the eCRF. Only in case the investigator is of the 
opinion that the SAE is a SUSAR, the investigator needs to inform the sponsor within 24 hours after 
awareness of the event. Assessment of seriousness, causality and expectedness for trials involving IMPs 
will be made by the PI or another authorised doctor. If an authorised doctor from the reporting site is 
unavailable, initial reports without causality and expectedness assessment should be submitted to the 
Sponsor, but must be followed-up by medical assessment as soon as possible thereafter. 
For each SUSAR the following information will need to be collected: 
 
full details in medical terms and case description 
 
event duration (start and end dates, if applicable) 
 
action taken 
 
outcome 
 
seriousness criteria 
 
causality (i.e. relatedness to trial drug / investigation), in the opinion of the investigator 
 
whether the event would be considered expected or unexpected. 
All SAEs assigned by the PI or delegate (or following central review) as both suspected to be related to 
IMP-treatment and unexpected will be classified as SUSARs and will be subject to expedited reporting to 
the Federal agency for medicines and health products (FAMHP). The Sponsor will inform the FAMHP, the 
EC and the Marketing Authorisation Holder of SUSARs within the required expedited reporting timescales. 
 
 


 
 
 
 
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Endpoints 
The following events will need to be marked as an “endpoint event” in the eCRF and will be reviewed by 
the Endpoint Adjudication Committee (EAC): 
 
All-cause mortality:  All deaths from any cause. This includes all cardiovascular and non-cardiovascular 
deaths. 
Cardiovascular death: Death fulfilling any of the following criteria: 
o 
Death due to proximate cardiac cause (e.g. myocardial infarction, cardiac tamponade, 
worsening heart failure) 
o 
Death caused by non-coronary vascular conditions such as neurological events, pulmonary 
embolism, ruptured aortic aneurysm, dissecting aneurysm, or other vascular disease 
o 
All procedure-related deaths, including those related to a complication of the procedure or 
treatment for a complication of the procedure (e.g. surgical or non-surgical revascularisation) 
o 
All valve-related deaths including structural or non-structural valve dysfunction or other valve 
related adverse events  
o 
Sudden death or unwitnessed death 
o 
Death of unknown cause 
 
Non-cardiovascular death: any death that is not thought to be due to a cardiovascular cause 
 
 
Rehospitalisation for heart failure is defined as either a hospital admission or an unscheduled contact 
at the emergency department for worsening HF if the patient is treated with intravenous loop diuretics.  
 
Need for Renal replacement therapy: ultrafiltration or dialysis 
 
The site will need to submit a complete endpoint package within 30 days upon request of the sponsor to 
advor@zol.be. This package should include anonymized source documents (SDs) relevant to the endpoint 
reported (e.g. discharge letter, emergency room notes, etc). The SD should include at least the reason for 
admission/death and the received treatment for the event (if applicable). The original SDs need to be 
retained at the site.  
Identifying a pregnancy 
All pre- menopausal women who are not surgically sterile will have pregnancy urine tests performed at 
screening phase (Day 1). A positive pregnancy test at day 1 constitutes in a screening failure.  
 
 


 
 
 
 
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9.3 Responsibilities 
Principal Investigator (PI):  
Checking for AEs when participants attend for treatment / follow-up. 
1. Using medical judgement in assigning seriousness, causality and expectedness using the Reference 
Safety Information approved for the trial. 
2. Ensuring that all SAEs and SUSARs are recorded in the eCRF. Ensuring that SUSARs are reported to the 
Sponsor and the Chief Investigator within 24 hours of becoming aware of the event and provide further 
follow-up information as soon as available.  
3. Ensuring that AEs are recorded and reported to the Sponsor and the Chief Investigator in line with the 
requirements of the protocol.  
Chief Investigator (CI) / delegate or independent clinical reviewer: 
1. Clinical oversight of the safety of patients participating in the trial, including an ongoing review of the risk / 
benefit. 
2. Using medical judgement in assigning seriousness, causality and expectedness of SAEs where it has not 
been possible to obtain local medical assessment. 
3. Immediate review of all SUSARs.  
4. Review of specific SAEs in accordance with the trial risk assessment and protocol. 
5. Assigning Medical Dictionary for Regulatory Activities (MedDRA) or Body System coding to all SAEs. 
6. Preparing the clinical sections and final sign off of the Development Safety Update Report (DSUR). 
Sponsor: 
1. Central data collection and verification of AEs, SAEs, and SUSARs according to the trial protocol.  
2. Reporting safety information to the CI, delegate or independent clinical reviewer for the ongoing 
assessment of the risk / benefit according to the Trial Monitoring Plan. 
3. Reporting safety information to the independent oversight committee identified for the trial (Trial Steering 
Committee (TSC)). 
4. Expedited reporting of SUSARs to the Competent Authority (FAMHP IN be) and EC within required 
timelines. 
5. Notifying Investigators of SUSARs that occur within the trial. 
6. The unblinding of a participant for the purpose of expedited SUSAR reporting. 
7. Checking for (annually) and notifying PIs of updates to the Reference Safety Information for the trial. 
8. Preparing standard tables and other relevant information for the DSUR in collaboration with the CI and 
ensuring timely submission to the FAMHP and EC. 


 
 
 
 
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Trial Steering Committee (TSC):  
In accordance with the Trial Terms of Reference for the TSC, periodically reviewing safety data. 
9.4 Notification of deaths 
All deaths will be reported to the sponsor within 5 working days of the research staff becoming aware of 
the event with coding of the reason of death (HF related, non-HF related, unknown). In case the death is 
deemed related to the IMP the event will need to be reported within 24 hours of awareness of the event.  
9.5 Reporting urgent safety measures  
If any urgent safety measures are taken the CI/Sponsor shall immediately and in any event no later than 3 
days from the date the measures are taken, give written notice to the FAMHP and the relevant EC of the 
measures taken and the circumstances giving rise to those measures. 
9.6 The type and duration of the follow-up of subjects after adverse events 
Once an adverse event is detected, it should be followed until its resolution or until it is judged to be 
permanent, and assessment should be made at each visit (or more frequently, if necessary) of any changes 
in severity, the suspected relationship to the study treatment, the interventions required to treat it, and the 
outcome.   
All SUSARs occurring from the time of the start of trial treatment until end of follow-up study phase (3 
months) must be recorded in the eCRF within 24 hours of the investigational staff becoming aware of the 
event.   
9.7 Development safety update reports 
The CI will provide (in addition to the expedited reporting above) DSURs once a year throughout the clinical 
trial, or on request, to the Competent Authority (FAMHP in Belgium), Ethics Committee and Sponsor. 
The report will be submitted within 60 days of the Developmental International Birth Date (DIBD) of the trial 
each year until the trial is declared ended 
 
 


 
 
 
 
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10 STATISTICS AND DATA ANALYSIS 
The statistical analysis been planned together with Geert Molenberghs and Liesbeth Bruckers from CenStat 
- University Hasselt. 
10.1 Sample size calculation 
The ADVOR study is powered for primary end-point which is the most relevant end-point with respect to 
the study hypothesis and reliable data from large randomized clinical trials are available to make a formal 
power calculation.  
In the DOSE trial, which recruited a similar study population as targeted in the ADVOR study, successful 
decongestion with a similar definition was approximately 11% vs 18% after 72 h in the low vs high-dose 
loop diuretics arm25. The high-dose loop diuretics arm of the DOSE trial is quite comparable to the standard 
of care group in the ADVOR study as the loop diuretic dose used in the latter is only slightly lower (2x 
instead of 2.5x the oral maintenance outpatient dose) and non-loop diuretics, which were infrequently used 
in the DOSE trial, are not allowed. Because of these slight differences, 15% is chosen as an estimate for 
occurrence of the primary end-point in the monotherapy with high-dose loop diuretics (SOC) group. 
No reliable data are available from large clinical trials to estimate occurrence of the primary end-point in 
the acetazolamide arm of the ADVOR study. Therefore, after thorough discussion with the advisory board 
as well as with Frank Hulstaert / Leen Verleye (KCE Trials) a success rate of 25% was chosen, which 
represents a clear meaningful benefit of 10% more patients with appropriate decongestion after 72 h. Using 
both estimates, considering a type I error rate α=0.05 and type II error rate β=0.20 (yielding a statistical 
power of 80%), the targeted sample size for the ADVOR study is calculated at n = 494. A 5% drop out has 
been calculated in order to estimate the total number of 519 patients to be enrolled in the study. 
10.2 Planned recruitment rate 
Patients will be recruited by approximately 24 Belgian sites within a period of approximately 24 months. 
The recruitment rate will start slow due to the site initiation activities at each center, which are performed in 
parallel during the first recruitment months. The inclusion criteria have been widened so almost all 
decompensated HF patients with volume overload might be suitable study candidates, which should lead 
to an easy recruitment of patients. In case recruitment would be lower than expected, the number of 
participating centers can be increased. Also, with the publication of three-monthly research letters to the 
participating sites and announcement through posters/leaflets of the ADVOR-study in the outpatient 
cardiology department, the inclusion process might be enhanced.  
10.3 Statistical analysis plan 
 
The treatment effect for the primary end-point [Treatment success (decongestion achieved) on the 
morning of day 4 without escalating diuretic strategy (doubling loop diuretic dose, addition of 
chlorthalidone, or ultrafiltration) during IV diuretic therapy on morning of day 3 is evaluated by means 


 
 
 
 
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of a generalized linear mixed model. The statistical model will include a fixed treatment effect and 
random center effect. 
 
For the first secondary end-point [occurrence of  the combined endpoint of all-cause mortality and heart 
failure readmission during 3 months of follow-up], a generalized linear mixed model for a binary 
outcome will be used.  The model will incorporate a fixed treatment effect and random center effect.  If 
the treatment effect on the composite endpoint of ‘all-cause mortality and HF readmission’ turns out to 
be statistically significant, both components will be evaluated separately in a hierarchical fashion with 
HF readmissions first and all-cause mortality second. For this analysis, HF readmission will include 
patient dying from HF during the 3 months of FU. As a sensitivity analysis the worst case scenario, 
assuming a HF readmission for all patients dying to non HF related causes during the 3 month follow-
up will be executed. 
 
Length of index hospitalization and change in quality of life scores are compared among treatment 
arms with a linear mixed model (fixed treatment effect and random center effect). Transformation will 
be employed when the model assumptions (such normality) are violated.  
 
All hypothesis are 2-sided and tested with a significance level  of  α=0.05. 
The proposed statistical models all assume the missing data mechanism to be missing at random. To 
investigate the sensitivity of the conclusions with respect to this assumption, a sensitivity analysis by means 
of multiple imputation technique will be performed.  
Secondary Analysis: 
 
All statistical models discussed in the secondary analysis include a fixed treatment effect and random 
effect for the center, and in case of longitudinal outcome random patient effects (intercept, slope).  
 
The mixed models for the primary and secondary end-point analyses will be extended with explanatory 
variables (such as gender, age, race, ethnicity, kidney function, neurohumoral blockers, diuretics and 
blood pressure)  
 
For the end-points collected repeatedly over time, the rate of change will be investigated using 
longitudinal data models. 
 
In case patients are re-hospitalized more than once for the same reason, i.e. HF readmission, models 
for recurrent events will be employed.   
 
To study the treatment effect on the evolution of  a patient's weight a mixed model for repeated 
measurements data will be used. The two treatment arms will also be compared for the area under the 
weight curve using an ANOVA model.  
 
For the first secondary end-point [time till combined endpoint of all-cause mortality and heart failure 
readmission during 3 months of follow-up], the Kaplan-Meier method will also be used to construct 
survival curves for both treatment arms. A mixed effects Cox proportional hazard model, with a fixed 
treatment effect and random center effect is used to investigate the treatment effect for this endpoint. 
The Hazard ratio with a 95% confidence interval will be obtained.  The appropriateness of the 
proportional hazard assumption will be examined. 


 
 
 
 
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 
For the primary and secondary endpoint subgroups analysis, with subgroups defined on the basis of 
LVEF, will also be performed. 
10.4 Data collection for economic evaluation 
In Belgium 2% of the population has HF, with 15.000 new cases being diagnosed annually and 3% of the 
annual health care budget is spent on HF, of which most is related to recurrent hospitalization for 
decompensated HF. HF decompensation often with repeated hospitalization has a tremendous negative 
impact on quality of life of the patients. Additionally, patients compare an episode of decompensation with 
‘drowning’ so they are in constant fear of recurrent decompensations. 
Reducing the number of hospital admittances will have an impact on the health care budget but also 
reducing the length of hospital stay per admittance will have a positive impact. 
According to the “Technische Cel voor de verwerking van de gegevens met betrekking tot ziekenhuizen” 
(MKG- MFG data of 2014, DRG 194 Hartfalen), 21784 patients were hospitalized for heart failure with an 
average hospital stay of 12 days in 2014. The average hospitalization costed 7015,44 €/patient, making up 
a total amount of 152.824.344 €. Of these patients, 10854 patients were hospitalized with advanced 
symptoms (NYHA III and NYHA IV) with a considerable longer hospitalization duration (17.55 days) and 
higher costs (10 873,77€/patient). Cost was inclusive of hospital-day-care-price, fees and pharmaceutical 
products. 
According to the MZG department of hospital ”Ziekenhuis Oost Limburg AV” HF patients with “majeure or 
extreme” HF (comparable with NYHA III and NYHA IV) have an average hospital stay of 9,12 days which 
is significant less then MKG- MFG data available. This reduction of the length of a hospital stay is a result 
of our HF care giver project as well as the clinical adoption of the use of more effective decongestive 
therapies often including Acetazolamide. The protocol has been scientifically validated and has been 
published also in Acta Cardiologica which is a peer-reviewed Belgian Cardiology Journal ((Determinants 
and impact of the natriuretic response to diuretic therapy in heart failure with reduced ejection fraction and 
volume overload. Acta Cardiol. 2015 Jun;70:265-73 + Implementation of Transmural Disease Management 
in Patients Admitted with Advanced Heart Failure. Acta Cardiol. 2014;69:145- 54).). 
The ADVOR trial will evaluate whether adding a low cost medication (Diamox ® 8.28 € public price/vial) on 
top of the standard treatment will reduce the hospital stay of admitted HF patients with 25% as well as 
reduce the need for renal replacement strategy. In daily practice this would result in an additional cost of < 
20€ to potentially reduce the average cost with at least 2500 € per hospitalised patient. This would also 
imply that acetazolamide, on top of usual care, has the potential to result in a direct cost saving of 
38.203.690 € in Belgium (=25% reduction on the budget actually spent on HF hospitalization). 
Additionally, it’s estimated that a more thorough successful decongestion will also lead to a reduction in 
heart failure rehospitalisation of 25% thereby further reducing health care cost. Therefore, a positive result 
of the ADVOR trial and wide adaptation of the therapeutic algorithm might translate into a reduction in 
expenses directly related to 1) a shorter hospitalization duration, 2) less costly ‘majeur or extreem’ HF, and 
3) less HF hospitalizations. 


 
 
 
 
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While these estimations might be considered ‘very optimistic’, they are merely a reflection of the potential 
impact of a reduction of hospitalisation duration as well as readmission seen in the Ziekenhuis Oost Limburg 
AV after implementation of the aforementioned care pathways including a better and faster decongestion 
with acetazolamide. However, assuming that the primary endpoint is reached (25% decongestion in the 
treatment group vs 15% in the standard of care), this would translate in a 11.7% relative risk reduction. If 
this would translate into a 11,7% reduction in heart failure related expenditure, an annual considerable cost-
saving of 17.880.408 € might still be reached. 
Importantly, due to the off-patent status of the drug tested in ADVOR there will never be an industry 
sponsored trial to support this hypothesis. Therefore, ADVOR will lead to a revival of a “forgotten” medicine 
because it has the potential to significantly impact the way we treat congestion in heart failure patients. 
Finally, it’s expected that ADVOR will result in a novel innovative approach of treatment of decompensated 
HF which is focused at a different level of the nephron to achieve better, easier and safer decongestion. In 
that way ADVOR might pave the way towards a complete change in thinking with regards to treating 
decompensated heart failure. 
This protocol has been designed with a later possible economic analysis in mind. Therefore, economical 
evaluation of the trial will be possible as several variables will be collected; 
- 
HF readmission 
- 
Length of hospital stay 
- 
Need for renal replacement therapy 
- 
Longitudinal assessment of QoL (EQ5D)….. 
As for any further data analyses, an economic analysis can of course be conducted by the sponsor of the 
trial and the chief investigator, totally independent from KCE. 
In addition, an economic analysis can be part of a KCE health technology assessment (HTA) project.  HTA 
projects are conducted by KCE at its own costs as part of its annual work programme approved by the KCE 
board, and following the KCE processes. The decision for KCE to perform a HTA on the topic will depend 
on the trial results and the prioritisation of the topic among the topics introduced that year. Each KCE HTA 
project includes a literature review. Data from different studies may be included. A meta-analysis may be 
conducted for that purpose, including the results or the coded individual data of the funded trial. HTA 
projects are conducted internally at KCE or are outsourced to a certain extent using a public tender 
procedure. In any case, KCE uses external experts during the project. For an HTA following a trial funded 
by KCE Trials, KCE would among others, invite the team of the chief investigator to act as external clinical 
experts to accompany the HTA project. 
 
 
 


 
 
 
 
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11 DATA HANDLING 
11.1 Data collection tools and source document identification 
It is the responsibility of the Principal Investigator at each site to maintain adequate and accurate source 
data, source documentation and CRFs to record all observations and other data pertinent to the clinical 
investigation in a timely manner. 
Patient’s personal data, which are included in the sponsor database shall be treated in compliance with all 
applicable laws and regulations. The data collected will be anonymized and the data will only be used for 
the purpose(s) of this trial.  
Source Data are defined as "All information in original records and certified copies of original records or 
clinical findings, observations, or other activities in a clinical trial necessary for the reconstruction and 
evaluation of the trial. Source data are contained in source documents (original records or certified copies)." 
Source Documents are defined as "Original documents, data and records (e.g., hospital records, clinical 
and office charts, laboratory notes, memoranda, subjects' diaries of evaluation checklists, pharmacy 
dispensing records, recorded data from automated instruments, copies or transcriptions certified after 
verification as being accurate and complete, microfiches, photographic negatives, microfilm or magnetic 
media, x-rays, subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial)." 
Case report form (CRF) is a form on which individual patient data required by the trial protocol are recorded.   
All data relating to the trial must be recorded in the eCRF (electronic CRF) prepared by the Sponsor. Data 
reported in the eCRF should be in English, consistent with the source data or the discrepancies should be 
explained. If information is not known, this must be clearly indicated in the eCRF. All missing and ambiguous 
data will be queried. 
The study data will be transcribed by study personnel from the source documents onto an eCRF, within 5 
working days of the subject’s visit.  
Worksheets may be used for the capture of some data to facilitate completion of the eCRF. Any such 
worksheets will become part of the subjects’ source documentation..  
Every effort should be made to ensure that all subjective assessments to be recorded in the eCRF are 
performed by the same individual who made the initial screening assessment.  
The Investigator must verify that all data entries in the eCRF are accurate and correct. All eCRF entries, 
corrections, and alterations must be made by the Investigator or other authorized study-site personnel. The 
Investigator or an authorized member of the investigational staff must adjust the eCRF (if applicable) and 
complete the query.  
ADVOR uses an eCRF which will be used to perform statistical analysis for the trial. The CRF will be 
constructed to ensure: 
 
adequate data collection  


 
 
 
 
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 
proper trails will be kept to demonstrate the validity of the trial (both during and after the trial) 
 
that only the data required by the protocol are captured in the CRF 
An annotated CRF is developed with coding conventions that will be used in the database. 
The Principal investigator is responsible to keep records of all participating patients (sufficient information 
to link records e.g., CRFs, hospital records and samples), all original signed informed consent forms and 
copies of the CRF pages. 
11.2 Data handling and record keeping 
All collected study data will be recorded in the CRF created with the software of CASTOR EDC.  
CASTOR EDC complies with all applicable medical data privacy laws and regulations: GCP, 21 CFR Part 
11, EU Annex 11, the European Data Protection Directive, ISO9001, and ISO27001/NEN7510.  
Once the PI and delegated member(s) of the investigational staff have been trained, they will receive the 
link of the eCRF together with a log-in account and password. Detailed information regarding the eCRF is 
provided in the Manual of Operations. 
Besides the data entered in the CRF, source documentation will need to be transferred to the sponsor if an 
endpoint (see section 9) has been reported. Only anonymised sourced data should be transferred to the 
sponsor. This transfer should be performed in accordance with the Belgian Privacy Act of 8 December 1992 
related to the protection of the privacy in the processing of personal data and as of the 25th of May 2018 
the Regulation (EU) 2016/679 of The European Parliament and of the Council of 27 April 2016 on the 
protection of natural persons with regard to the processing of personal data and on the free movement of 
such data, and repealing Directive 95/46/EC (General Data Protection Regulation), and as of the 5th of 
September 2018 the Law of 30 July 2018 related to the protection of natural persons with regard to the 
processing of personal data, and the Law of 22 August 2002 related to the rights of patients, including their 
respective Royal Decrees). Detailed information regarding the transfer of source documents to the sponsor 
is provided in the Manual of Operations. 
 
11.3 Access to Data 
Direct access will be granted to authorised representatives from the Sponsor, host institution and the 
regulatory authorities to permit trial-related monitoring, audits and inspections. 
11.4 Archiving 
 
archiving will be authorised by the Sponsor following submission of the end of study report 
 
It is the responsibility of the Principal Investigator at each site to ensure all essential trial 
documentation and source records (e.g. signed Informed Consent Forms, Investigator Site Files, 
patients’ hospital notes, etc.) at their site are securely retained for at least 25 years 
 
The sponsor will be responsible for archiving all CRF documents and trial database for at least 
25 years 


 
 
 
 
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 
Therefore, all essential documents will be archived for a minimum period after completion of trial 
as required by the applicable legislation 
 
12 MONITORING, AUDIT & INSPECTION 
A Trial Monitoring Plan will be developed and agreed by the TMG based on the trial risk assessment which 
will be done by exploring the trial dataset or performing site visits. 
The Sponsor will perform on-site monitoring visits as frequently as necessary. The monitor will record dates 
of the visits in a study center visit log that will be kept at the site. The first post-initiation visit will be made 
as soon as possible after enrollment at the center has begun. Monitoring might be initially conducted across 
all sites, and subsequently conducted using a risk based approach that focuses, for example, on sites that 
have the highest enrolment rates, large numbers of withdrawals, or atypical (low or high) numbers of 
reported adverse events. At these visits, the monitor will compare the data entered into the CRFs with the 
hospital or clinic records (source documents). The nature and location of all source documents will be 
identified to ensure that all sources of original data required to complete the CRF are known to the Sponsor, 
Chief Investigator and investigational staff and are accessible for verification by the Sponsor site contact. 
If electronic records are maintained at the investigational site, the method of verification must be discussed 
with the investigational staff. The processes reviewed can relate to participant enrolment, consent, 
eligibility, and allocation to trial groups; adherence to trial interventions and policies to protect participants, 
including reporting of harm and completeness, accuracy, and timeliness of data collection 
Direct access to source documentation (medical records) must be allowed for the purpose of verifying that 
the data recorded in the CRF are consistent with the original source data, patients informed consent will be 
obtained hereto. Findings from this review of CRFs and source documents will be discussed with the 
investigational staff. The Sponsor expects that, during monitoring visits, the relevant investigational staff 
will be available, the source documentation will be accessible, and a suitable environment will be provided 
for review of study-related documents. The monitor will meet with the Investigator on a regular basis during 
the study to provide feedback on the study conduct.  
 
 
 


 
 
 
 
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13 ETHICAL AND REGULATORY CONSIDERATIONS 
13.1 Ethics Committee (EC) review & reports 
 
Before the start of the trial, approval will be sought from a EC for this trial protocol, informed 
consent forms and other relevant documents e.g. insurance documents, advertisements and GP 
information letters 
 
Substantial amendments that require review by EC will not be implemented until the EC grants a 
favourable opinion for the study (note that amendments may also need to be reviewed and 
accepted by the FAMHP before they can be implemented in practice at sites) 
 
All correspondence with the EC will be retained in the Trial Master File/Investigator Site File  
 
An annual progress report (APR) will be submitted to the EC within 30 days of the anniversary 
date on which the favourable opinion was given, and annually until the trial is declared ended 
 
It is the Chief Investigator’s responsibility to produce the annual reports as required. 
 
The Chief Investigator will notify the EC of the end of the study 
 
If the study is ended prematurely, the Chief Investigator will notify the EC, including the reasons 
for the premature termination 
 
Within one year after the end of the study, the Chief Investigator will submit a final report with the 
results, including any publications/abstracts, to the EC 
13.2 Peer review 
The protocol has been reviewed by KCE (the funder). 
In addition, ADVOR has undergone a high quality peer review by two individual experts who have 
knowledge of the relevant discipline to consider the clinical and/or service based aspects of the protocol, 
and/or have the expertise to assess the methodological and statistical aspects of the study.  
13.3 Public and Patient Involvement 
At least 2 % of the Belgian population has heart failure (HF), with 15.000 new cases being diagnosed 
annually and 3% of the annual health care budget spent on HF, the most of which is related to recurrent 
hospitalization for decompensated HF. These hospitalizations have a tremendous negative impact on the 
quality of life of patients.  
Therefore, ADVOR will be a RCT with patient and public involvement at all stages of the clinical research. 
Indeed, ADVOR actually is a result of an active partnership between patients, members of the public 
including KCE / health care administrators, and researchers in the research process. More specifically  all 
endpoints of ADVOR are patient-centric measures (i.e.primary endpoint of decongestion) with a formal 
power calculation. Unfortunately, powering a study for hard cardiovascular endpoints would need 


 
 
 
 
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thousands of patients with corresponding budgets and would not be feasible within the Belgian context. 
Fortunately, successful decongestion (i.e. free of volume overload) has been proved study after study to 
be a relevant clinical outcome strongly associated with overall prognosis and was therefore chosen as the 
primary end-point for the ADVOR trial. It’s also very patient relevant. In addition, secondary endpoints: all-
cause mortality, HF readmission length of stay, and QoL are also very patient-centric.  
In addition, the primary and secondary outcome measures are in line with the COMET (Core Outcome 
Measures in Effectiveness Trials) initiative. Indeed ‘decongestion’ (being dry is for the patient a very 
important improvement in symptomatology), heart failure readmission, all-cause mortality, length of stay, 
quality of life can all be considered standardized relevant core outcomes sets. Therefore, the core outcomes 
relevant for any acute heart failure study will be collected and reported, making it easier for the results of 
ADVOR to be compared, contrasted and combined as appropriate with other trials (Zannad F et al, 
European Journal of Heart Failure, 2013;15:1082-1094). Additionally, we will continue to explore other 
tertiary outcomes, which are often mechanistically very interesting, as well. 
The protocol has also been discussed with members of “Mon Coeur Entre Parenthèses” which is a patient 
association representing HF patients and their family. 
We will also collect the dosages of neurohumoral blocker therapy throughout the study period, thereby 
hopefully facilitating a better implementation of guideline recommended therapy. As guidelines recommend 
a specific dosage for each of these drugs, it’s easy to standardize the intake of such medications to be 
used in an accurate analysis. This will be done as an exploratory tertiary end-point. 
Finally, strategies that reduce the number of hospital admittances / length of stay will have an immediate 
impact on the health care budget.  
13.4 Regulatory Compliance  
The trial will not commence until a Clinical Trial Authorisation (CTA) is obtained from the FAMPH and EC. 
The protocol and trial conduct shall be governed and construed in accordance with the laws of Belgium. 
The Trial will for instance comply with the Belgian law of May 7th 2004 regarding experiments on the human 
person and any relevant amendments. 
The validity, interpretation and performance of this Protocol shall be governed and construed in accordance 
with the laws of Belgium. Belgian courts have the exclusive jurisdiction.  
13.5 Protocol compliance  
Protocol deviations, non-compliances, or breaches are departures from the approved protocol. 
 
Prospective, planned deviations or waivers to the protocol are not allowed and must not be used 
e.g. it is not acceptable to enrol a subject if they do not meet the eligibility criteria or restrictions 
specified in the trial protocol 
 
Accidental protocol deviations can happen at any time. They must be adequately documented and 
explained on the relevant forms and reported to the Chief Investigator and Sponsor immediately.  


 
 
 
 
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 
Deviations from the protocol which are found to frequently recur are not acceptable, will require 
immediate action and could potentially be classified as a serious breach. 
 
13.6 Notification of Serious Breaches to GCP and/or the protocol  
A “serious breach” is a breach which is likely to effect to a significant degree 
 
the safety or physical or mental integrity of the subjects of the trial; or 
 
the scientific value of the trial 
 
The sponsor and the Chief Investigator will be notified immediately of any case where the above definition 
applies during the trial conduct phase. 
The sponsor of the clinical trial will notify the licensing authority in writing of any serious breach of the 
conditions and principles of GCP in connection with that trial; or the protocol relating to that trial, as 
amended from time to time, within 7 days of becoming aware of that breach. 
13.7 Data protection and patient confidentiality  
All investigators and trial site staff must comply with the requirements of the Regulation (EU) 2016/679 of 
April 27, 2016 of the European Parliament and the Council Concerning the protection of individuals with 
regard to the processing of personal data and the free movement of such data and repealing Directive 
95/46 / EC ( general data Protection Regulation), the Belgian Privacy Act of 8 December 1992 on the 
protection of privacy in relation to the processing of personal data and as of the 5th of September 2018 the 
Law of 30 July 2018 related to the protection of natural persons with regard to the processing of personal 
data, the Law of 22 August 2002 related to the rights of patients, including their respective Royal Decrees), 
with regards to the collection, storage, processing and disclosure of personal information and will uphold 
the Act’s core principles.  
 
Therefore, 
 
personal information will be collected, kept secure, and maintained in a way that is conform all 
regulation concerning privacy  
 
the creation of coded, depersonalised data where the participant’s identifying information is 
replaced by an unrelated sequence of characters 
 
secure maintenance of the data and the linking code in separate locations using encrypted digital 
files within password protected folders and storage media 
 
limiting access to the minimum number of individuals necessary for quality control, audit, and 
analysis with a list of persons who have access to data, and all this conform the regulation 
concerning privacy 
 
the confidentiality of data will be preserved when the data are transmitted to sponsors and co-
investigators 
 
the data will be stored for at least 25 years 


 
 
 
 
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 
The data custodians are prof. dr. Mullens, Evi Theunissen and Joke Vanlangenaeker. 
13.8 Financial and other competing interests for the chief investigator, PIs at each site 
and committee members for the overall trial management  
As acetazolamide is an off-patent drug, no competing interests that might influence trial design, conduct, 
or reporting are present for any of the chief investigator, PIs at each site and committee members for the 
overall trial management. 
13.9 Indemnity 
1. The Sponsor will ensure appropriate insurance to meet the potential legal liability of the Sponsor(s) for 
harm to participants arising from the management of the research. Before the start of the trial, approval will 
be sought from the EC. 
2.  The Sponsor will ensure appropriate insurance for legal liability of the Sponsor(s) or employer(s) for harm 
to participants arising from the design of the research. Before the start of the trial, approval will be sought 
from the EC. 
3. The participating sites will ensure appropriate insurance to meet the potential legal liability of 
investigators/collaborators arising from harm to participants in the conduct of the research. 
13.10 Access to the final trial dataset 
Only the steering group has access to the full trial dataset in order to ensure that the overall results are not 
disclosed by an individual trial site prior to the main publication.  
However, site investigators will be allowed to access the full dataset if a formal request describing their 
plans is approved by the steering group. 
 
 


 
 
 
 
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14 DISSEMINATION POLICY 
14.1 Dissemination policy 
Upon completion,  
 
the data arising from the trial will be owned by the sponsor 
 
the data will be analysed and tabulated and a Final Study Report prepared 
 
the full study report can be accessed on the website of KCE as well as on ClinicalTrials.gov 
 
participating investigators will have rights to publish any of the trial data upon approval of the 
steering committee 
 
The publication containing the primary study results should be finalized within 6 months of the 
statistical analysis. There are no time limits or review requirements on the additional publications. 
 
Funding by KCE will be acknowledged within the publications  
 
The participants of the trial will be notified by a letter containing the outcome of the trial by 
provision of the publication and/or via a specifically designed newsletter 
 
The participant might specifically request results from their PI upon completion of the trial, which 
might be provided once the results have been published  
 
It’s foreseen that at the latest at publication, a machine readable electronic copy of the published 
version or final peer-reviewed manuscript accepted for publication in a repository for scientific 
publications will be deposit (open access). The research data needed to validate the results 
presented in the scientific publications will be deposited. 
Upon completion, the study will also be submitted for presentation at the annual European Society of 
Cardiology in the late-breaking Clinical Trial Session as well as during the Annual European Heart Failure 
Association meeting. 
The primary study results of ADVOR will be reported fully and made publicly available when the research 
has been completed. All researchers shall ensure that the outcome of the research is prepared as a 
research paper for publication in a suitable peer-reviewed, preferably open-access, journal. In addition, the 
database of the ADVOR study will be available for further sub-analysis per request of any of the sub-
investigators. As a result, we feel that at least 10 other publications might be possible based on the data 
collected in ADVOR study which might all help to treat decompensated HF patients better. The Consort 
Guidelines and checklist will be reviewed prior to generating any publications for the trial to ensure they 
meet the standards required for submission to high quality peer reviewed journals etc. http://www.consort-
statement.org/ 
All participating investigators will also try to disseminate their research findings to the broader public as well 
as to the research participants when the study has completed. 


 
 
 
 
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Endpoints were meticulously chosen based on consensus of all participating investigators including 
European Heart Failure Association as well as HF patient organisation (Mon Coeur Entre Parenthèses). 
Therefore, a positive result will also have the potential to be adopted soon in the national and international 
guidelines to treat decompensated HF patients.  
In conclusion, it’s felt that a positive endpoint might lead to a fast adoption of the use of acetazolamide in 
the treatment of ADHF patients because of 
1) Publication in top ranked cardiology journal 
2) Presentation of study results in national and international cardiology meetings 
3) Adoption in guidelines 
4) Internationally recognized expert study team 
14.2 Authorship eligibility guidelines and any intended use of professional writers 
For ADVOR, the Steering Committee will comprise the Publication Committee. KCE may serve as members 
of the committee. This committee will manage study publications with the goal of publishing findings from 
the data. The Publication Committee will develop the final Publication Plan as a separate document. In 
addition, the committee will apply and reinforce the authorship guidelines set forth in the Publication Plan. 
Membership in the Publication Committee does not guarantee authorship. The committee will meet at 
regular intervals. 
Publications will adhere to authorship criteria defined by the International Committee of Medical Journal 
Editors (ICMJE, Uniform requirements for manuscripts submitted to biomedical journals, www.icmje.org). 
Individual authorship criteria defined by the target journal or conference will be followed when it differs from 
ICMJE criteria. Authors, including KCE representatives, must at a minimum meet all of the conditions below: 
 
Substantial contribution to conception and design, or acquisition of data, or analysis and 
interpretation of data; AND 
 
Drafting the article or revising it critically for important intellectual content; AND 
 
Final approval of the version to be published; AND 
 
Agreement to be accountable for all aspects of the work in ensuring that questions related to the 
accuracy or integrity of any part of the work are appropriately investigated and resolved. 
Decisions regarding authorship and contributorship will be made by the committee. The selected authors 
will be responsible for drafting the publication. All selected authors must fulfill the authorship conditions 
stated above to be listed as authors, and all contributors who fulfill the conditions must be listed as authors. 
All investigators not listed as co-authors will be acknowledged as the “ADVOR Study Investigators” and will 
be individually listed according to the guidelines of the applicable scientific journal when possible. Any other 
contributors will be acknowledged by name with their specific contribution indicated. Based on the 
recruitment, site investigators might also be part of the Authorship.  
 
A methods paper describing the ADVOR study, as well as the publication containing the primary study 
results will be drafted by the Chief Investigator, and submitted for publication after approval of the members 


 
 
 
 
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of the steering committee.  
 
 


 
 
 
 
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15 REFERENCES 
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Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela 
BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, 
McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein 
J, Turan TN, Virani SS, Wong ND, Woo D and Turner MB. Heart disease and stroke statistics 2013 
update: a report from the American Heart Association. Circulation. 2013;127:e6-e245. 
2. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive 
heart failure. The SOLVD Investigators. N Engl J Med. 1991;325:293-302. 
3. Cohn JN, Johnson G, Ziesche S, Cobb F, Francis G, Tristani F, Smith R, Dunkman WB, Loeb H, Wong 
M and et al. A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic 
congestive heart failure. N Engl J Med. 1991;325:303-10. 
4. Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM and Shusterman NH. The effect 
of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart 
Failure Study Group. N Engl J Med. 1996;334:1349-55. 
5. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet. 1999;353:9-13. 
6. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in 
Congestive Heart Failure (MERIT-HF). Lancet. 1999;353:2001-7. 
7. Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P, Rouleau JL, Tendera M, Castaigne 
A, Roecker EB, Schultz MK and DeMets DL. Effect of carvedilol on survival in severe chronic heart 
failure. N Engl J Med. 2001;344:1651-8. 
8. Flather MD, Shibata MC, Coats AJ, Van Veldhuisen DJ, Parkhomenko A, Borbola J, Cohen-Solal A, 
Dumitrascu D, Ferrari R, Lechat P, Soler-Soler J, Tavazzi L, Spinarova L, Toman J, Bohm M, Anker 
SD, Thompson SG and Poole-Wilson PA. Randomized trial to determine the effect of nebivolol on 
mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur 
Heart J. 2005;26:215-25. 
9. Cohn JN and Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic 
heart failure. N Engl J Med. 2001;345:1667-75. 
10. Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J, 
Yusuf S, Pocock S, Investigators C and Committees. Effects of candesartan on mortality and morbidity 
in patients with chronic heart failure: the CHARM-Overall programme. Lancet. 2003;362:759-66. 
11. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, Palensky J and Wittes J. The effect of 
spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone 
Evaluation Study Investigators. N Engl J Med. 1999;341:709-17. 
12. Zannad F, McMurray JJ, Krum H, van Veldhuisen DJ, Swedberg K, Shi H, Vincent J, Pocock SJ and 
Pitt B. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364:11-
21. 


 
 
 
 
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13. Swedberg K, Komajda M, Bohm M, Borer JS, Ford I, Dubost-Brama A, Lerebours G, Tavazzi L and 
Investigators S. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-
controlled study. Lancet. 2010;376:875-85. 
14. McMurray JJ, Packer M, Desai AS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Solomon 
SD, Swedberg K, Zile MR, Investigators P-H and Committees. Angiotensin-neprilysin inhibition versus 
enalapril in heart failure. N Engl J Med. 2014;371:993-1004. 
15. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, 
White BG, DeVries DW and Feldman AM. Cardiac-resynchronization therapy with or without an 
implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140-50. 
16. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L and Tavazzi L. The effect 
of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-
49. 
17. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA, 3rd, Foster E, Greenberg 
H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D and Zareba W. Cardiac-resynchronization therapy 
for the prevention of heart-failure events. N Engl J Med. 2009;361:1329-38. 
18. Tang AS, Wells GA, Talajic M, Arnold MO, Sheldon R, Connolly S, Hohnloser SH, Nichol G, Birnie DH, 
Sapp JL, Yee R, Healey JS and Rouleau JL. Cardiac-resynchronization therapy for mild-to-moderate 
heart failure. N Engl J Med. 2010;363:2385-95. 
19. Adams KF, Jr., Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR, Abraham WT, Berkowitz RL, 
Galvao M and Horton DP. Characteristics and outcomes of patients hospitalized for heart failure in the 
United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute 
Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2005;149:209-16. 
20. Forman DE, Butler J, Wang Y, Abraham WT, O'Connor CM, Gottlieb SS, Loh E, Massie BM, Rich MW, 
Stevenson LW, Young JB and Krumholz HM. Incidence, predictors at admission, and impact of 
worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 2004;43:61-
7. 
21. Testani JM, Chen J, McCauley BD, Kimmel SE and Shannon RP. Potential effects of aggressive 
decongestion during the treatment of decompensated heart failure on renal function and survival. 
Circulation. 2010;122:265-72. 
22. Testani JM, Cappola TP, Brensinger CM, Shannon RP and Kimmel SE. Interaction between loop 
diuretic-associated mortality and blood urea nitrogen concentration in chronic heart failure. J Am Coll 
Cardiol. 2011;58:375-82. 
23. Testani JM, Kimmel SE, Dries DL and Coca SG. Prognostic importance of early worsening renal 
function after initiation of angiotensin-converting enzyme inhibitor therapy in patients with cardiac 
dysfunction. Circ Heart Fail. 2011;4:685-91. 
24. Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V, Piovanelli B, Carubelli V, Bugatti S, 
Lombardi C, Cotter G and Dei Cas L. Is worsening renal function an ominous prognostic sign in patients 
with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail. 
2012;5:54-62. 


 
 
 
 
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25. Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, 
Rouleau JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, 
Givertz MM, Semigran MJ, Bart BA, Mascette AM, Braunwald E and O'Connor CM. Diuretic strategies 
in patients with acute decompensated heart failure. N Engl J Med. 2011;364:797-805. 
26. Schnermann J. Juxtaglomerular cell complex in the regulation of renal salt excretion. Am J Physiol. 
1998;274:R263-79. 
27. Knauf H and Mutschler E. Sequential nephron blockade breaks resistance to diuretics in edematous 
states. J Cardiovas Pharmacol. 1997;29:367-72. 
28. Verbrugge FH, Dupont M, Bertrand PB, Nijst P, Penders J, Dens J, Mullens W. Determinants and 
impact of the natriuretic response to diuretic therapy in heart failure with reduced ejection fraction and 
volume overload. Acta cardiologica. 2015;70:265-73. 
29. Knauf H, Mutschler E. Sequential nephron blockade breaks resistance to diuretics in edematous states. 
J Cardiovasc Pharmacol. 1997;29:367-72. 
30. Mullens W, Verbrugge FH, Nijst P, Tang WH. Renal sodium avidity in heart failure: from 
pathophysiology to treatment strategies. Eur Heart J. 2017 2017;38:1872-1882. 
31. Lala A McNulty SE, Mentz RJ, et al. Relief and recurrence of congestion during and after hospitalization 
for acute heart failure: insights from diuretic optimization strategy evaluation in acute decompensated 
heart failure 'DOSE-AHF) and cardiorenal rescue study in acute decompensated heart failure 
(CARRESS-HF). Circ Heart Fail. 2015;8:741-8. 
32. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the 
emergency diagnosis of heart failure. N Engl J Med 2002;347:161-7 
33. Januzzi JL, Jr., Camargo CA, Anwaruddin S, et al. The N-terminal Pro-BNP. Investigation of Dyspnea 
in the Emergency department (PRIDE) study. Am J Cardiol 2005;95:948-54. 
 
 
 


 
 
 
 
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 APPENDICES 
 
16 APPENDIX 1: AUTHORISATION OF PARTICIPATING SITES  
Appendix 1.1. Required documentation  
Prior to submitting the trial to the Ethics Committee, the Principal Investigator (PI) is required to sign a 
protocol signature page confirming his/her agreement to conduct the trial in accordance with these 
documents and all of the instructions and procedures found in this protocol. 
Detailed information regarding the mandatory documentation which are required before the trial can start 
at the participating sites can be found in the Manual of Operations. 
Appendix 1.2. Procedure for initiating/opening a new site  
Once all start-up documentation (see Manual of Operations) from the participating site is available at the 
sponsor and the IMP/study material is available at the participating site, the sponsor will send confirmation 
by e-mail to the PI that the study can start. Only upon receipt of this site activation confirmation the site can 
screen/enrol patients.  
Appendix 1.3. Principal Investigator responsibilities  
The PI is the responsible leader of the investigational team of the participating site. The PI is responsible 
that he/she and his/her investigational team conducts the trial according the instructions and procedures 
documented in this protocol. Full list of PI’s legal responsibilities is listed in the Clinical Trial Agreement. 
The PI has the primary responsibility to protect the rights and welfare of the patient in the trial. The PI’s 
primary responsibilities also include the following: 
- Delegation of Responsibilities 
PI must personally perform or delegate to qualified sub-investigator or investigational staff all of the 
necessary tasks to carry out this trial. Even when specific tasks are delegated, the PI remains 
ultimately responsible for proper conduct of the trial and fulfilment of all associated obligations. 
- Oversight of Investigational Team 
The PI must provide members of the investigational team with sufficient oversight, training and 
information to facilitate appropriate safety procedures and protocol adherence. In addition, the EC 
must be informed if a PI is no longer able to fulfil his or her duties for any reason including, but not 
limited to, traveling for a prolonged period of time. 
- Evaluation of Adequacy of Resources 
Pis must ensure that adequate resources (facilities, equipment, supplies, and personnel) exist to 
conduct the research, protect subjects and ensure the integrity of the research. 


 
 
 
 
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- Document Retention 
The PI must ensure adequate and accurate source documents and trial records that include all 
pertinent observations on each of the site’s trial patients. Source data should be attributable, legible, 
contemporaneous, original, accurate and complete. PI must ensure that this source data is reported 
to the sponsor in the CRF and in the required reports according to the timelines defined in this protocol. 
 
 
 
 


 
 
 
 
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17 APPENDIX 2: EQ-5D QUESTIONNAIRE (DUTCH) 
 
Vink onder elke titel het ENE vakje aan dat het best uw gezondheid VANDAAG beschrijft. 
MOBILITEIT 
 
Ik heb geen problemen met rondwandelen 
 
Ik heb een beetje problemen met rondwandelen 
 
Ik heb matige problemen met rondwandelen 
 
Ik heb ernstige problemen met rondwandelen 
 
Ik ben niet in staat om rond te wandelen 
 
ZELFZORG 
 
Ik heb geen problemen met mijzelf te wassen of aan te kleden 
 
Ik heb een beetje problemen met mijzelf te wassen of aan te kleden 
 
Ik heb matige problemen met mijzelf te wassen of aan te kleden 
 
Ik heb ernstige problemen met mijzelf te wassen of aan te kleden 
 
Ik ben niet in staat mijzelf te wassen of aan te kleden 
 
DAGELIJKSE ACTIVITEITEN (bijv. werk, studie, huishouden, gezins- en 
vrijetijdsactiviteiten) 
 
Ik heb geen problemen met mijn dagelijkse activiteiten 
 
Ik heb een beetje problemen met mijn dagelijkse activiteiten 
 
Ik heb matige problemen met mijn dagelijkse activiteiten 
 
Ik heb ernstige problemen met mijn dagelijkse activiteiten 
 
Ik ben niet in staat mijn dagelijkse activiteiten uit te voeren 
 
PIJN / ONGEMAK 
 
Ik heb geen pijn of ongemak 
 
Ik heb een beetje pijn of ongemak 
 
Ik heb matige pijn of ongemak 
 
Ik heb ernstige pijn of ongemak 
 
Ik heb extreme pijn of ongemak 
 
ANGST / DEPRESSIE 
 
Ik ben niet angstig of depressief 
 
Ik ben een beetje angstig of depressief 
 
Ik ben matig angstig of depressief 
 
Ik ben erg angstig of depressief 
 
Ik ben extreem angstig of depressief 
 
 
 
 


 
 
 
 
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 
We willen weten hoe goed of slecht uw gezondheid VANDAAG is. 
 
Deze meetschaal (te vergelijken met een thermometer) is genummerd van 0 
tot 100. 
 
100 staat voor de beste gezondheid die u zich kunt voorstellen. 
0 staat voor de slechtste gezondheid die u zich kunt voorstellen. 
 
Plaats een X op de meetschaal om aan te geven hoe uw gezondheid 
VANDAAG is. 
 
Noteer nu het getal dat u aangeduid hebt op de meetschaal in het 
onderstaande vakje. 
 
  
 
 
 
 
UW GEZONDHEID VANDAAG = 
10
0 
20
30
40
50
60
80
70
90
100 
5 
15
25
35
45
55
75
65
85
95


 
 
 
 
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18 APPENDIX 3 : EQ-5D QUESTIONNAIRE (FRENCH) 
 
Pour chaque rubrique, veuillez cocher UNE case, celle qui décrit le mieux votre santé AUJOURD’HUI. 
Mobilité 
 
Je n’ai aucun problème pour me déplacer à pied 
 
J’ai des problèmes légers pour me déplacer à pied 
 
J’ai des problèmes modérés pour me déplacer à pied 
 
J’ai des problèmes sévères pour me déplacer à pied 
 
Je suis incapable de me déplacer à pied 
 
Autonomie de la personne 
 
Je n’ai aucun problème pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes légers pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes modérés pour me laver ou m’habiller tout(e) seul(e) 
 
J’ai des problèmes sévères pour me laver ou m’habiller tout(e) seul(e) 
 
Je suis incapable de me laver ou de m’habiller tout(e) seul(e) 
 
Activités courantes (exemples: travail, études, travaux ménagers, activités 
familiales ou loisirs) 
 
Je n’ai aucun problème pour accomplir mes activités courantes 
 
J’ai des problèmes légers pour accomplir mes activités courantes 
 
J’ai des problèmes modérés pour accomplir mes activités courantes 
 
J’ai des problèmes sévères pour accomplir mes activités courantes 
 
Je suis incapable d’accomplir mes activités courantes 
 
Douleurs / gêne 
 
Je n’ai ni douleur ni gêne 
 
J’ai des douleurs ou une gêne légère(s) 
 
J’ai des douleurs ou une gêne modérée(s) 
 
J’ai des douleurs ou une gêne sévère(s) 
 
J’ai des douleurs ou une gêne extrême(s) 
 
Anxiété / Dépression 
 
Je ne suis ni anxieux(se), ni déprimé(e) 
 
Je suis légèrement anxieux(se) ou déprimé(e) 
 
Je suis modérément anxieux(se) ou déprimé(e) 
 
Je suis sévèrement anxieux(se) ou déprimé(e) 
 
Je suis extrêmement anxieux(se) ou déprimé(e) 
 
 
 
 
 


 
 
 
 
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 
Nous aimerions savoir dans quelle mesure votre santé est bonne ou 
mauvaise AUJOURD’HUI. 
 
Cette échelle est numérotée de 0 à 100. 
 
100 correspond à la meilleure santé que vous puissiez imaginer. 
0 correspond à la pire santé que vous puissiez imaginer. 
 
Veuillez faire une croix (X) sur l’échelle afin d’indiquer votre état de santé 
AUJOURD’HUI. 
 
Maintenant, veuillez noter dans la case ci-dessous le chiffre que vous avez 
coché sur l’échelle. 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
VOTRE SANTÉ AUJOURD’HUI = 
10
0
20
30
40
50
60
80
70
90
100 
5
15
25
35
45
55
75
65
85
95


 
 
 
 
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19 APPENDIX 4 : URINARY COLLECTION PROCEDURE 
Urinary collection procedure: 
Patients need to empty their bladder before the administration of the start dose of loop diuretics.  
The urinary collection needs to start immediately after first bolus administration of loop diuretics and 
acetazolamide or placebo and the collection will stop the latest as close to but prior to the morning bolus of 
study medication on day 3. This collection will be defined as the Total Urinary Collection in the study. 
Importantly, the total volume needs to be written down in the study files as this is will be used for tertiary 
end-point analysis and is needed for the clinician to decide if escalation of therapy is needed. 
Total Urinary Collection equals the sum of Urinary Collection period 1 + Urinary Collection period 2: 
Urinary Collection period 1 = Urine collection that starts immediately after first bolus administration until the 
morning of day 2. This Urinary Output 1 value will be reported in the CRF together with start- and stop 
date/time of this first collection period.  
Urinary Collection period 2 = Urine collection that starts with the end of Urinary Output 1 until the morning 
of day 3 prior to the morning bolus of study medication. This Urinary Output 2 value will be reported in the 
CRF together with start- and stop date/time of this second collection period. 
How to collect the urine? 
Urinary catheter insertion is strongly recommended but not mandatory to achieve an optimal urine 
collection. However, in case of urinary incontinence, placement of a urinary catheter is mandatory.  
Alternatively, the patient needs to use (an) urinary container(s) to collect ALL urine. Prior to the stop of 
urinary collection period the patient need to be instructed to empty their bladder. Care should be taken to 
ensure ALL urine is collected.  
At the end of a Urinary Collection period all urine of this period needs to be collected in the urinary 
container(s). 
Which measurements need to be done?  
For each urinary collection period the container(s) or a sample (if multiple containers are kept, they need 
to be mixed before taking a sample) will need to be sent to the local lab for analysis of the volume, Cr, total 
protein and Na (and bumetanide level, if available). 
 
 
 
 


 
 
 
 
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Page 74 of 75 
20 APPENDIX 5 : CONCOMITANT MEDICATION  
During the trial the Principal Investigator or delegated team member should check if the subject is taking 
concomitant medication (CM).  
 
The CM which need to be recorded for the trial can be divided in 3 different types of concomitant medication 
(CM): 
 
Neurohumoral blockers: renin-angiotensin system blockers, sacubitril/valsartan, beta-blockers, 
and mineralocorticoid receptor antagonists 
 
Diuretics 
 
Other concomitant medication: pre-defined list of medication (ivabradine, hydralazine, 
molsidomine, etc.) The full list of other CM can be found in the current eCRF version.  
 
Depending on the visit day, specific types of CM will need to be recorded in the eCRF 
 
Visit 
Neurohumoral blocker(s) 
Diuretic(s) 
Other CM 
Screening 
X 
X 
X 
Day 1, 2, 3 
X 
X 
Day 4 
X 
X 
X 
Discharge,  
3 month FU 
X 
X 
x 
 
 
During the screening phase, the daily maintenance dose of the neurohumoral blockers and diuretics will 
need to be recorded in the eCRF. In addition, the list of the other concomitant medication will need to be 
reported in the eCRF. 
 
During the treatment phase, the list of other concomitant medications will need to be reviewed on a daily 
basis. Listed medication which the subject is treated with, will need to be reported in the eCRF on the 
respectively day of treatment. Additionally on day 4 also the daily dose of the neurohumoral blockers and 
diuretics will need to be recorded in the eCRF.  
 
During the follow-up phase, the daily dose of neurohumoral blockers and diuretics the subject is taking 
at the time of discharge and 3 month FU visit will need to be recorded in the eCRF. The list of other 
concomitant medications will need to be reported at the time of discharge and 3 months. In addition, it 
needs to be reported in the eCRF if the subject received iron treatment during the treatment phase and/or 
during the follow-up phase.  
 
 


 
 
 
 
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21 APPENDIX 6 : AMENDMENT HISTORY  
Amendment 
No. 
Protocol 
version no. 
Date issued 
Details of changes made 
01 
Version 2.0 
03 January 
2019 
Cfr. explanation below. 
List details of all protocol amendments here whenever a new version of the protocol is produced. 
Protocol amendments must be submitted to the Sponsor for approval prior to submission to the EC 
committee or FAMHP. 
 
Details of changes made for amendment No. 01: 
 
- Clarification of maintenance dose of loop diuretics. To avoid any confusion, half of start dose given at 
randomization has been erased and we stated “1x orally daily maintenance dose”. 
- Clarification volume assessment scoring 
- If patients are being discharged earlier than day 4, parameters planned for the morning of day 4 will still 
be assessed but at discharge (i.e. EQ5D, NT-proBNP/BNP, blood samples for sub-study if applicable) 
- Removal of an endpoint event, i.e. rehospitalisation due to any cardiac event. 
- Clarification exclusion criteria:  
 Use of nitrates and/or molsidomine is allowed, but at the discretion of the treating physician 
instead of use of nitrates is allowed only when systolic blood pressure is above 140mmHg. 
 Treatment with acetazolamide within one month prior to randomization is not allowed instead 
of treatment with acetazolamide during the index hospitalisation before randomization. 
 Use of any non-protocol defined diuretic agent with the exception of mineralocorticoid 
receptor antagonists during the treatment phase of the study is not allowed instead of Use of 
any non-protocol defined diuretic agent with the exception of mineralocorticoid receptor antagonists. 
- Addition of one exclusion criteria: Subjects with urinary incontinence who are not willing to receive a 
bladder catheter 
- Collection of additional study data: 
 Use of iron per os and/or intravenously throughout the study will be recorded at discharge and at 
follow-up. 
 A predefined list of concomitant medication will need to be completed at discharge and at 3 months 
follow-up (cfr. appendix 5) 
- Details concerning the collection of concomitant medication have been replaced by appendix 5. 
- Follow-up appointment will be 3 months (+ 14 days) after the start of study medication, instead of after 
hospital discharge. 
- For completeness, admission has been changed to screening.  
- Throughout the protocol, minor changes (e.g. typographical errors, clarifications, etc.) have been added. 
 
 
 


 
Original Statistical Analysis Plan 
Version - 1.0 
17th of January 2022 
 


 
 
 
 
 
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A multi-centre, randomized, double-blind, phase IV clinical trial on the 
diuretic effects of Acetazolamide (Diamox ®) in patients with 
Decompensated heart failure and Volume OveRload 
 
 
 
STATISTICAL ANALYSIS PLAN 
Version number: version 1.0  
Version date: 17 January 2022 
 
 
RESEARCH REFERENCE NUMBERS 
EudraCT Number: 
2018-001345-14 
Clinical trials.gov Number: 
NCT03505788 
SPONSOR Number: 
ZOLCAR17001 
FUNDER Number: 
KCE-17001 
Protocol version: 
2.0, dated 03/01/2019 
 
 
 




 
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2 TABLE OF CONTENTS 
1 
DOCUMENT HISTORY ........................................................................................................................ 2 
2 
TABLE OF CONTENTS ....................................................................................................................... 3 
3 
LIST OF ABBREVIATIONS ................................................................................................................. 4 
4 
STUDY SYNOPSIS .............................................................................................................................. 5 
4.1 
STUDY OBJECTIVES AND ENDPOINTS ........................................................................................................... 6 
4.1.1 
Rationale ............................................................................................................................................. 6 
4.1.2 
Primary Objective and outcome measure ............................................................................................ 6 
4.1.3 
Secondary objectives and endpoints ................................................................................................... 7 
4.1.4 
Safety objectives and endpoints .......................................................................................................... 8 
4.1.5 
Exploratory objectives and endpoints .................................................................................................. 9 
4.2 
PATIENT POPULATION ................................................................................................................................... 10 
4.2.1 
Inclusion Criteria ................................................................................................................................ 10 
4.2.2 
Exclusion Criteria ............................................................................................................................... 10 
4.3 
INTERVENTION ................................................................................................................................................ 11 
4.3.1 
STOP TREATMENT .......................................................................................................................... 11 
4.3.2 
Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response ............................ 12 
4.3.3 
Background therapy ........................................................................................................................... 12 
4.3.4 
Randomisation and blinding .............................................................................................................. 12 
4.4 
ENDPOINT ADJUDICATION ............................................................................................................................ 13 
4.5 
SAMPLE SIZE ................................................................................................................................................... 14 
5 
STATISTICAL ANALYSIS ................................................................................................................. 14 
5.1 
GENERAL PRINCIPLES ................................................................................................................................... 14 
5.2 
INTERIM ANALYSES ........................................................................................................................................ 15 
5.3 
MULTIPLICITY ADJUSTMENT ......................................................................................................................... 15 
5.4 
BLIND REVIEW ................................................................................................................................................. 15 
5.5 
DATA SETS TO BE ANALYSED ....................................................................................................................... 15 
5.6 
SUBJECT DISPOSITION .................................................................................................................................. 15 
5.7 
VIOLATIONS AND DEVIATIONS ...................................................................................................................... 15 
5.8 
CONCOMITANT THERAPIES .......................................................................................................................... 16 
5.9 
BASELINE CHARACTERISTICS ...................................................................................................................... 16 
5.10 
ANALYSIS OF THE PRIMARY OUTCOME ...................................................................................................... 16 
5.10.1 
Main analysis ..................................................................................................................................... 16 
5.10.2 
Subgroup analysis ............................................................................................................................. 16 
5.10.3 
Treatment of missing data ................................................................................................................. 17 
5.10.4 
Other sensitivity analyses .................................................................................................................. 17 
5.11 
ANALYSIS OF SECONDARY OUTCOMES ...................................................................................................... 18 
5.11.1 
Secondary outcome 1 ........................................................................................................................ 18 
5.11.2 
Secondary outcome 2 ........................................................................................................................ 19 
5.11.3 
Secondary outcome 3 ........................................................................................................................ 19 
5.12 
ANALYSIS OF SAFETY OUTCOMES .............................................................................................................. 20 
6 
SIGNATURES .................................................................................................................................... 20 
7 
APPENDIX A – BASELINE CHARACTERISTICS ........................................................................... 21 
7.1 
PATIENT CHARACTERISTICS AND BASELINE COMPARISONS .................................................................. 21 
8 
REFERENCE ..................................................................................................................................... 24 
 
















 
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receptor antagonists during the treatment phase of the study. Thiazides, metolazone, 
indapamide and amiloride should be stopped upon study inclusion. If patient is taking a 
combination drug including a thiazide-type diuretic, the thiazide-type diuretic should be 
stopped. 
- 
Current use of sodium-glucose transporter-2 inhibitors 
- 
Subjects who are pregnant or breastfeeding  
- 
Subjects with urinary incontinence who are not willing to receive a bladder catheter. 
 
4.3 
Intervention 
At the moment of randomization, oral loop diuretics are stopped and the patient receives an IV bolus 
of loop diuretics at a dose equal to the double of his oral daily maintenance dose with a maximal dose 
of 5 mg bumetanide (=200 mg furosemide). Bumetanide is the preferred loop diuretic agent to be used 
in this trial. Between administering the start dose and next treatment dose a minimum of 6 hours is 
required. During the remaining part of the treatment phase, the patient will continue to receive 2 IV 
treatment doses every day provided that the treating physician has concluded during the morning 
rounds that the patient is still volume overloaded (see Figures 2, volume assessment score > 1). The IV 
loop diuretic dose will be the orally daily maintenance dose, administered between 8:00 and 12:00 
am, together with an intravenous bolus of 500 mg of acetazolamide or placebo. The second dose of IV 
loop diuretics, again dosing equal to the orally daily maintenance dose, will be given 6 hours after the 
morning dose. Any patient with more than trace oedema, residual pleural effusion or residual ascites 
would be considered to be still volume overloaded (see Figures 2). Residual pleural effusion and/or 
ascites should always be confirmed by chest X-ray or echography. If pleural effusion/ascites is used as 
an inclusion criteria, chest X-ray and/or echography should be repeated until decongestion has been 
achieved (volume assessment score ≤ 1). If not present at inclusion, new evidence of pleural effusion 
and/or ascites may arise during the treatment phase, but if scored it should be confirmed by a chest 
X-ray or echography. If the patient is not volume overloaded anymore, the intravenous administration 
of study medication should be stopped. Once decongestion is achieved (volume assessment score ≤ 1) 
during the treatment phase, no volume assessment should be performed anymore the following 
morning. 
 
4.3.1 
STOP TREATMENT 
The treating physician is allowed (but not obliged) to stop the study treatment, in case of persistent 
volume-overload in following cases: 
- 
symptomatic hypotension with a systolic blood pressure <100 mmHg 
- 
asymptomatic hypotension with a systolic blood pressure <90 mmHg 
- 
an increase of serum Creatinine levels x 1.5 of the serum Creatinine level compared to 
admission value 
- 
occurrence of metabolic acidosis (pH < 7.2) 
The discontinuation of the study treatment will be seen as a failure for the primary endpoint 
(decongestion not achieved).  However, if any of these events occur when the patient is judged to 
be euvolemic, the study treatment is stopped and the primary endpoint is considered to be 
successful (decongestion achieved).  
 
Freedom from volume-overload (i.e. successful  decongestion) on the morning of day 4 will be 
defined as not more than trace oedema, no residual pleural effusion, and no residual ascites (Figure 
2). 


 
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4.3.2 
Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response  
If the total urinary output on the morning of day 3 is < 3500 mL and the patient is still volume 
overloaded, an escalation of decongestive treatment is mandatory. One of the outlined three 
options can be chosen at the discretion of the treating physician. 
Escalation therapy options: 
- 
doubling of the IV dose of the loop diuretics  
- 
add oral chlorthalidone 50 mg once daily 
- 
ultrafiltration or renal replacement therapy might be considered 
The decision to proceed with escalation therapy will be collected in the case report as the need for 
escalation implies a failure for the primary endpoint.  
 
4.3.3 
Background therapy  
24h oral intake of fluid and sodium will be restricted to 1500 mL and 1.5 g, respectively. It is 
recommended that all patients receive the same maintenance infusion with 500 mL glucose 5% and 
3g MgSO4 administered over 24h time interval, until complete decongestion or end of the study 
treatment phase. All non-protocol fluids administered (including those for administration of 
intravenous medication) should be limited.  
 
In case of serum potassium levels <4 mmol/L, 40 mmol of KCI is added to the maintenance infusion. 
Oral potassium supplements may be used at the discretion of the treating physician, but their use 
will be prospectively registered. 
 
In case of metabolic acidosis with serum bicarbonate levels <20 mmol/L, it is recommended to 
administer intravenously 100 ml of NaHCO3 8.4%. 
 
Treatment 
with 
neurohumoral 
blockers 
(e.g. 
renin-angiotensin 
system 
blockers, 
sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists) may be continued 
at the same or lower dosage at the discretion of the treating physician, until the end of the 
treatment phase (max 4 days) or until complete decongestion is achieved, whatever comes first. 
Dose increases for any of these medications are not allowed during the screening and treatment 
phase with the exception of mineralocorticoid receptor antagonists in case of hypokalemia despite 
intravenous potassium supplement. In addition, starting an SGLT2 inhibitor and a switch from renin-
angiotensin system blockers to sacubitril/valsartan is not allowed during the screening and 
treatment phase, but might be pursued after decongestion is achieved. After decongestion, it is 
strongly recommended to up-titrate doses of neurohumoral blockers according to the guidelines in 
the HFrEF patients. Dosages of neurohumoral blockers are collected at screening, at discharge and 
at three months follow-up.  
 
4.3.4 
Randomisation and blinding 
The ADVOR study is a randomized double blind clinical trial with 2 treatment arms; therapy with 
high-dose loop diuretics and placebo vs therapy with high-dose loop diuretics and acetazolamide. 
An automated web-based system is used to randomly assign patients in a 1:1 ratio with variable 
blocks sizes, stratified for LVEF according to study centre. To ensure an equal proportion of HFpEF 


 
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versus HFrEF patients in both study arms, the population will be stratified at inclusion according to 
LVEF ≤40% versus >40%. Permuted block randomization according to centre and LVEF stratum will 
be used to achieve this.  
 
Patient, site personnel, sponsor personnel and data analysts will remain blinded to the identity of 
the treatment from the time of randomization until database lock. Though we do not foresee 
serious adverse events related to the study drug, the study code should only be broken for valid 
medical or safety reasons e.g. in the case of a severe adverse event where it is necessary for the 
investigator or treating health care professional to know which treatment the patient is receiving 
before the participant can be treated.  
Following rules apply for unblinding; 
- 
Rapid unblinding of a patient can be performed by a physician of the study team. 
Detailed information concerning the unblinding procedures is provided in the Manual of 
Operations.  
- 
On receipt of the treatment allocation details, the PI or treating health care professional 
will continue to deal with the participant’s medical emergency as appropriate. 
- 
The PI/Investigation team documents the breaking of the code and the reasons for doing 
so on the medical notes and eCRF. It will also be documented at the end of the trial in 
any final study report and/or statistical report. 
 
Unblinded data are to be kept strictly confidential until the time of unblinding of the trial and will 
not be accessible by anyone else involved in the trial with the following exceptions: (1) the Project 
Manager of the company responsible for the labelling and packaging of the IMP, (2) the IRT system 
programmers who work on the randomization and drug management system; and (3) the data 
manager who prepares reports required for regulatory reporting (suspected unexpected serious 
adverse reactions [SUSAR] reporting). These individuals will not be involved in the day-to-day 
running of the study. 
 
4.4 
Endpoint adjudication 
Because the primary endpoint requires physical examination of the blinded study physician, 
adjudication of the primary event is not possible. However, all admission labelled as HF readmission, 
all-cause mortality and the need for renal replacement therapy will be adjudicated by the Endpoint 
Adjudication Committee (EAC)  
 
For the endpoints HF readmission, all-cause mortality and the need for renal replacement therapy  a 
complete endpoint package will need to be send to the sponsor. This package should include 
anonymized source documents (SDs) relevant to the endpoint reported (e.g. discharge letter, 
emergency room notes, etc). The SD should include at least the reason for admission/death and the 
received treatment for the event (if applicable). This package will be assessed by the Endpoint 
adjudication members of the Endpoint adjudication committee.  
 
In case of discrepancy between the evaluation of the EAC members regarding the same event, the Trial 
Data Manager will contact the EAC members to inform them on the discrepancies found so the both 
of them can come to a final decision. The discrepancies and the final decision will be documented. 
 


 
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4.5 
Sample Size 
The ADVOR study is powered for primary endpoint which is the most relevant endpoint with respect 
to the study hypothesis and reliable data from large randomized clinical trials are available to make a 
formal power calculation.  
In the DOSE trial, which recruited a similar study population as targeted in the ADVOR study, successful 
decongestion with a similar definition was approximately 11% vs 18% after 72 h in the low vs high-dose 
loop diuretics arm. The high-dose loop diuretics arm of the DOSE trial is quite comparable to the 
standard of care group in the ADVOR study as the loop diuretic dose used in the latter is only slightly 
lower (2x instead of 2.5x the oral maintenance outpatient dose) and non-loop diuretics, which were 
infrequently used in the DOSE trial, are not allowed. Because of these slight differences, 15% is chosen 
as an estimate for occurrence of the primary endpoint in the monotherapy with high-dose loop 
diuretics (SOC) group. 
 
No reliable data are available from large clinical trials to estimate occurrence of the primary endpoint 
in the acetazolamide arm of the ADVOR study. Therefore, after thorough discussion with the advisory 
board a success rate of 25% was chosen, which represents a clear meaningful benefit of 10% more 
patients with appropriate decongestion after 72 h. Using both estimates, considering a type I error 
rate α=0.05 and type II error rate β=0.20 (yielding a statistical power of 80%), the targeted sample size 
for the ADVOR study is calculated at n = 494. A 5% drop out has been calculated in order to estimate 
the total number of 519 patients to be enrolled in the study. 
 
5 STATISTICAL ANALYSIS 
5.1 
General principles 
This statistical analysis plan dated 17 January 2022 is based on the statistical information documented 
in the study protocol version 2.0 dated 03 January 2019 (see section 10), the methods paper published 
in the European Journal of Heart Failure (2018)3 and guidance by the European Medicines Agency 
(EMA)4 and the Food and Drug Administration5 regarding the management of clinical trials during 
COVID-19 pandemic (2021). 
 
The scope of this statistical analysis plan is to outline the statistical tools used for the primary and 
secondary objectives of the ADVOR study following the procedures documented in the study protocol 
version 2.0 dated 03 January 2019 in all participating centres.  
 
Prior to the statistical analysis the collected study data will be cleaned by the data management team 
of the Clinical Trial Unit at the Ziekenhuis Oost-Limburg (ZOL-CTU). The cleaning will be performed 
according to the Data Management Plan agreed for the ADVOR trial.  
 
All statistical hypothesis are 2-sided and a 5% significance level will be used.  A correction for multiple 
testing will not be implemented.  
 
Trial results will be reported according to the CONSORT statement on reporting randomized controlled 
trials.  
For the analysis of the primary outcome, each secondary and exploratory outcome the following 
information will be presented: 
- 
the number of patients included in each analysis, by treatment arm  
- 
a summary statistic of the outcome (e.g. number (%), mean (SD)), by treatment arm  


 
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- 
the estimated treatment effect  
- 
a 95% confidence interval for the estimated treatment effect  
- 
A two-sided p-value for all analyses, a significance level of 5% will be used. 
 
All statistical analysis will be done with Statistical Analysis System (SAS) for Windows, SAS 9.4. 
5.2 
Interim analyses 
No interim analysis is planned regarding the ADVOR study. 
 
5.3 
Multiplicity adjustment 
There will be no correction for multiplicity of testing as there is only one primary endpoint. All other 
endpoints and subgroup analyses will be considered as exploratory. 
 
5.4 
Blind review 
Once the database is cleaned the dataset will be locked and transferred to  an independent academic 
statistical center (DSI/CenStat - University Hasselt) for efficacy and safety analysis according to the  
statistical analysis plan  
 
5.5 
Data sets to be analysed 
For the primary endpoint the statistical analysis will be based on an intention-to-treat analysis set 
(ITTAS) including all randomized patients.  Patients will be analysed according to the treatment group 
they were allocated to according to the electronic randomization system (irrespective of the actual 
treatment received).  
 
For the secondary endpoints the statistical analyses will be based on the same data set as will be used 
for the primary endpoint analysis.  
 
For the safety endpoints, all patients that were randomized and received at least 1 dose of the 
investigated drug or placebo will be included (safety population). For the safety analysis, patients will 
be grouped based on the actual study treatment received.  
 
5.6 
Subject disposition 
After closing of the database, a CONSORT diagram will be produced for transparent status of the 
subject reporting. 
 
5.7 
Violations and deviations 
The important protocol deviations listed below will be summarised by randomized treatment group 
- 
Patients who were randomized but did not meet inclusion and exclusion criteria 
- 
Patients who received study treatment with a wrong treatment vial number at any time during 
the study 
- 
Patients who received only acetazolamide/placebo but no loop diuretics on day 1, 2 or 3 






 
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The treatment effect for the primary endpoint is evaluated by means of a generalized linear mixed 
model, including a fixed treatment effect and random centre effect.  As a sensitivity analysis, the 
model will be extended by including a fixed effect (binary) indicating if the endpoint was assessed 
before or after the first identified COVID-19 case in Belgium dated 03 February 2020 and the 
interaction term between this variable and treatment. 
 
5.11 Analysis of secondary outcomes 
All statistical models implemented for the analysis of the secondary outcomes are mixed-effects 
models, including a fixed treatment effect and random centre effect. For the outcomes measured at 
multiple time points also random patient effects (intercept, slope) are included.  
 
5.11.1 Secondary outcome 1 
The combined endpoint of all-cause mortality and HF readmission during 3 months of follow-up, 
will be analysed as a binary and as a time-to-event endpoint.  
 
- 
For descriptive purposes, the number (%) of failure and success for the combined 
outcome of all-cause mortality and HF readmission during 3 months of follow-up will be 
given per treatment arm.  To investigate the treatment effect on the occurrence of the 
combined endpoint, a generalized linear mixed model for a binary outcome will be 
employed.  The model will incorporate a fixed treatment effect and random centre 
effect.  The results of this model will be presented as odds-ratio, 95% confidence interval 
and the associated p value.  
 
If the treatment effect on the composite endpoint of ‘all-cause mortality and HF 
readmission’ turns out to be statistically significant, both components will be evaluated 
separately in a hierarchical fashion with HF readmissions first and all-cause mortality 
second. For this analysis, HF readmission will include patients dying from any cause 
during the 3 months of FU.  The treatment effect, on the components, will be 
investigated by the same statistical model as used for the combined endpoint. 
 
- 
To investigate the treatment effect on the time until combined endpoint of all-cause 
mortality and HF readmission during 3 months of follow-up a survival analysis will be 
performed. Time to event is defined as the time between day 1 and the date of (first) HF 
readmission or death if there was no HF readmission. The analysis will be censored at 3 
months of follow-up or at the time when the patient was last known to be alive (for 
patients that withdraw or are lost to follow up), whichever occurs earlier.  Survival times 
will be summarised descriptively using Kaplan-Meier survival curves. Formal testing for 
a difference in time to event will be done using a mixed-effect Cox proportional hazard 
model including the treatment arm and a random centre effect (ie, using a shared frailty 
model). The proportional hazards assumption will be verified by plotting log cumulative 
hazard versus log-time for the intervention and SOC group. Model validity will be further 
explored using plots of Cox-Snell and Martingale residuals. The treatment effect will be 
summarised as the hazard ratio (HR), 95% CI and associated p value.  
 
 
 


 
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To assess whether the treatment effect differs according subgroups defined on the basis of LVEF 
(see table in section 5.10.2) a subgroup analysis will be performed. The statistical model formulated 
for the analysis of this endpoints (binary and time to event version) will be extended to include a 
fixed effect for the subgroup and an interaction term between the study arm and the subgroup. 
The interaction term will be considered significant at the 5% level. Within each subgroup, summary 
statistics of the outcome by treatment arm will be presented; the OR/HR for the treatment effect 
and 95% confidence interval.  A p-value for the interaction test will also be reported.  
 
5.11.2 Secondary outcome 2 
For each treatment arm mean, median and interquartile range for length of index hospitalization 
will be presented for patients who survived to hospital discharge.   The effect of treatment on length 
of index hospitalization, for patients who survived to hospital discharge,  is compared among 
treatment arms with a linear mixed model8 (fixed treatment effect and random centre effect). A log 
transformation will be employed as the model assumptions (such normality) will likely be violated. 
Model assumptions will be investigated by means of diagnostic plots. The results of this model will 
be presented as (geometric) mean length of index hospitalization (and 95% CI) per treatment group, 
the geometric mean ratio (GMR), 95% CI and associated p value.  
 
To assess whether the treatment effect differs according subgroups defined on the basis of LVEF 
(see table in section 5.10.2) a subgroup analysis will be performed. The statistical model formulated 
for the analysis of this endpoint will be extended to include a fixed effect for the subgroup and an 
interaction term between the study arm and the subgroup. The interaction term will be considered 
significant at the 5% level. Within each subgroup, summary statistics of the outcome by treatment 
arm will be presented; the GMR for the treatment effect and 95% confidence interval.  A p-value 
for the interaction test will also be reported.  
 
5.11.3 Secondary outcome 3 
The QoL scores (EQ-5D total score and EQ-VAS)  will be presented using line plots for each study 
arm to illustrate trends over time.  Depending on the distribution of the data, the means and 95% 
CI of means or medians and inter-quartile ranges at baseline, the morning of day 4 or discharge 
(whatever comes first), and at 3 months of follow up will be reported. Evolution in the QoL will be 
investigated via a linear mixed model, with the Qol score of morning of day 4 or discharge (whatever 
comes first), and 3 months follow up as the longitudinal dependent variable, with a fixed treatment 
effect, day, the interaction of treatment by day, and baseline QoL, random centre effect and 
random patient effect (intercept, slope) will be used. Model assumptions will be investigated by 
means of diagnostic plots. Transformation will be employed when the model assumptions (such 
normality) are violated.   
The analysis will be performed following the recommendations of the Belgian guidelines for health 
economic evaluation to value health care resource use will be used: 
https://kce.fgov.be/nl/een-belgische-waardenset-voor-de-eq-5d-5l-%E2%80%93-hoe-
gezondheidsgerelateerde-levenskwaliteit-waarderen  
 
A subgroup analysis with subgroups defined on the basis of LVEF, will also be performed. 
 










 
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8  REFERENCE 
 
1 Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau 
JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, 
Semigran MJ, Bart BA, Mascette AM, Braunwald E and O'Connor CM. Diuretic strategies in patients with acute 
decompensated heart failure. N Engl J Med. 2011;364:797-805.  
 
2 Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, VanLente 
F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to 
estimate glomerular filtration rate. Ann Intern Med. 2009 May 5; 150(9):604-12 
 
3  Mullens, W., Verbrugge, F. H., Nijst, P., Martens, P., Tartaglia, K., Theunissen, E., Bruckers, L., Droogne, 
W., Troisfontaines, P., Damman, K., Lassus, J., Mebazaa, A., Filippatos, G., Ruschitzka, F., & Dupont, M. 
(2018). Rationale and design of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume 
Overload) trial. European Journal of Heart Failure, 20(11), 1591-1600. https://doi.org/10.1002/ejhf.1307.  
 
4 European Medicines Agency. Guidance on the management of clinical trials during the COVID-19 
(coronavirus) 
pandemic, 
version 
4, 
February 
04 
2021. 
https://ec.europa.eu/health/sites/default/files/files/eudralex/vol-10/guidanceclinicaltrials covid19 en.pdf  
(accessed January 14, 2022). 
 
5 US Food and Drug Administration. FDA guidance on conduct of clinical trials of medical products during 
COVID-19 public health emergency, August 2021. https://www.fda.gov/regulatory-information/search-fda-
guidance-documents/fda-guidance-conduct-clinical-trials-medical-products-during-covid-19-public-health-
emergency (accessed January 14, 2022).  
 
6 Kahan BC. Accounting for centre-effects in multicentre trials with a binary outcome - when, why, and how? 
BMC medical research methodology. 2014;14:20. 
 
7 Molenberghs, G. and Verbeke, G. (2005). Modelsfor Discrete Longitudinal Data. New York: Springer.  
 
8 Verbeke, G. and Molenberghs, F. (2000). Linear Mixed Models for Longitudinal Data. New York: Springer. 
                                                     


 
Final Statistical Analysis Plan 
Version - 2.0 
17th of March 2022 


 
 
 
 
 
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A multi-centre, randomized, double-blind, phase IV clinical trial on the 
diuretic effects of Acetazolamide (Diamox ®) in patients with 
Decompensated heart failure and Volume OveRload 
 
 
 
STATISTICAL ANALYSIS PLAN 
Version number: version 2.0  
Version date: 17 March 2022 
 
 
RESEARCH REFERENCE NUMBERS 
EudraCT Number: 
2018-001345-14 
Clinical trials.gov Number: 
NCT03505788 
SPONSOR Number: 
ZOLCAR17001 
FUNDER Number: 
KCE-17001 
Protocol version: 
2.0, dated 03/01/2019 
 
 
 




 
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2 TABLE OF CONTENTS 
1 
DOCUMENT HISTORY ........................................................................................................................ 2 
2 
TABLE OF CONTENTS ....................................................................................................................... 3 
3 
LIST OF ABBREVIATIONS ................................................................................................................. 4 
4 
STUDY SYNOPSIS .............................................................................................................................. 5 
4.1 
STUDY OBJECTIVES AND ENDPOINTS ........................................................................................................... 6 
4.1.1 
Rationale ............................................................................................................................................. 6 
4.1.2 
Primary Objective and outcome measure ............................................................................................ 6 
4.1.3 
Secondary objectives and endpoints ................................................................................................... 7 
4.1.4 
Safety objectives and endpoints .......................................................................................................... 8 
4.1.5 
Exploratory objectives and endpoints .................................................................................................. 9 
4.2 
PATIENT POPULATION ................................................................................................................................... 10 
4.2.1 
Inclusion Criteria ................................................................................................................................ 10 
4.2.2 
Exclusion Criteria ............................................................................................................................... 10 
4.3 
INTERVENTION ................................................................................................................................................ 11 
4.3.1 
STOP TREATMENT .......................................................................................................................... 11 
4.3.2 
Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response ............................ 12 
4.3.3 
Background therapy ........................................................................................................................... 12 
4.3.4 
Randomisation and blinding .............................................................................................................. 12 
4.4 
ENDPOINT ADJUDICATION ............................................................................................................................ 13 
4.5 
SAMPLE SIZE ................................................................................................................................................... 14 
5 
STATISTICAL ANALYSIS ................................................................................................................. 14 
5.1 
GENERAL PRINCIPLES ................................................................................................................................... 14 
5.2 
INTERIM ANALYSES ........................................................................................................................................ 15 
5.3 
MULTIPLICITY ADJUSTMENT ......................................................................................................................... 15 
5.4 
BLIND REVIEW ................................................................................................................................................. 15 
5.5 
DATA SETS TO BE ANALYSED ....................................................................................................................... 15 
5.6 
SUBJECT DISPOSITION .................................................................................................................................. 15 
5.7 
VIOLATIONS AND DEVIATIONS ...................................................................................................................... 15 
5.8 
CONCOMITANT THERAPIES .......................................................................................................................... 16 
5.9 
BASELINE CHARACTERISTICS ...................................................................................................................... 16 
5.10 
ANALYSIS OF THE PRIMARY OUTCOME ...................................................................................................... 16 
5.10.1 
Main analysis ..................................................................................................................................... 16 
5.10.2 
Subgroup analysis ............................................................................................................................. 16 
5.10.3 
Treatment of missing data ................................................................................................................. 17 
5.10.4 
Other sensitivity analyses .................................................................................................................. 17 
5.11 
ANALYSIS OF SECONDARY OUTCOMES ...................................................................................................... 18 
5.11.1 
Secondary outcome 1 ........................................................................................................................ 18 
5.11.2 
Secondary outcome 2 ........................................................................................................................ 19 
5.11.3 
Secondary outcome 3 ........................................................................................................................ 19 
5.12 
ANALYSIS OF SAFETY OUTCOMES .............................................................................................................. 20 
6 
SIGNATURES .................................................................................................................................... 20 
7 
APPENDIX A – BASELINE CHARACTERISTICS ........................................................................... 21 
7.1 
PATIENT CHARACTERISTICS AND BASELINE COMPARISONS .................................................................. 21 
8 
REFERENCE ..................................................................................................................................... 24 
 
















 
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receptor antagonists during the treatment phase of the study. Thiazides, metolazone, 
indapamide and amiloride should be stopped upon study inclusion. If patient is taking a 
combination drug including a thiazide-type diuretic, the thiazide-type diuretic should be 
stopped. 
- 
Current use of sodium-glucose transporter-2 inhibitors 
- 
Subjects who are pregnant or breastfeeding  
- 
Subjects with urinary incontinence who are not willing to receive a bladder catheter. 
 
4.3 
Intervention 
At the moment of randomization, oral loop diuretics are stopped and the patient receives an IV bolus 
of loop diuretics at a dose equal to the double of his oral daily maintenance dose with a maximal dose 
of 5 mg bumetanide (=200 mg furosemide). Bumetanide is the preferred loop diuretic agent to be used 
in this trial. Between administering the start dose and next treatment dose a minimum of 6 hours is 
required. During the remaining part of the treatment phase, the patient will continue to receive 2 IV 
treatment doses every day provided that the treating physician has concluded during the morning 
rounds that the patient is still volume overloaded (see Figures 2, volume assessment score > 1). The IV 
loop diuretic dose will be the orally daily maintenance dose, administered between 8:00 and 12:00 
am, together with an intravenous bolus of 500 mg of acetazolamide or placebo. The second dose of IV 
loop diuretics, again dosing equal to the orally daily maintenance dose, will be given 6 hours after the 
morning dose. Any patient with more than trace oedema, residual pleural effusion or residual ascites 
would be considered to be still volume overloaded (see Figures 2). Residual pleural effusion and/or 
ascites should always be confirmed by chest X-ray or echography. If pleural effusion/ascites is used as 
an inclusion criteria, chest X-ray and/or echography should be repeated until decongestion has been 
achieved (volume assessment score ≤ 1). If not present at inclusion, new evidence of pleural effusion 
and/or ascites may arise during the treatment phase, but if scored it should be confirmed by a chest 
X-ray or echography. If the patient is not volume overloaded anymore, the intravenous administration 
of study medication should be stopped. Once decongestion is achieved (volume assessment score ≤ 1) 
during the treatment phase, no volume assessment should be performed anymore the following 
morning. 
 
4.3.1 
STOP TREATMENT 
The treating physician is allowed (but not obliged) to stop the study treatment, in case of persistent 
volume-overload in following cases: 
- 
symptomatic hypotension with a systolic blood pressure <100 mmHg 
- 
asymptomatic hypotension with a systolic blood pressure <90 mmHg 
- 
an increase of serum Creatinine levels x 1.5 of the serum Creatinine level compared to 
admission value 
- 
occurrence of metabolic acidosis (pH < 7.2) 
The discontinuation of the study treatment will be seen as a failure for the primary endpoint 
(decongestion not achieved).  However, if any of these events occur when the patient is judged to 
be euvolemic, the study treatment is stopped and the primary endpoint is considered to be 
successful (decongestion achieved).  
 
Freedom from volume-overload (i.e. successful  decongestion) on the morning of day 4 will be 
defined as not more than trace oedema, no residual pleural effusion, and no residual ascites (Figure 
2). 


 
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4.3.2 
Treatment DOSE ADJUSTMENTS in case of an inappropriate diuretic response  
If the total urinary output on the morning of day 3 is < 3500 mL and the patient is still volume 
overloaded, an escalation of decongestive treatment is mandatory. One of the outlined three 
options can be chosen at the discretion of the treating physician. 
Escalation therapy options: 
- 
doubling of the IV dose of the loop diuretics  
- 
add oral chlorthalidone 50 mg once daily 
- 
ultrafiltration or renal replacement therapy might be considered 
The decision to proceed with escalation therapy will be collected in the case report as the need for 
escalation implies a failure for the primary endpoint.  
 
4.3.3 
Background therapy  
24h oral intake of fluid and sodium will be restricted to 1500 mL and 1.5 g, respectively. It is 
recommended that all patients receive the same maintenance infusion with 500 mL glucose 5% and 
3g MgSO4 administered over 24h time interval, until complete decongestion or end of the study 
treatment phase. All non-protocol fluids administered (including those for administration of 
intravenous medication) should be limited.  
 
In case of serum potassium levels <4 mmol/L, 40 mmol of KCI is added to the maintenance infusion. 
Oral potassium supplements may be used at the discretion of the treating physician, but their use 
will be prospectively registered. 
 
In case of metabolic acidosis with serum bicarbonate levels <20 mmol/L, it is recommended to 
administer intravenously 100 ml of NaHCO3 8.4%. 
 
Treatment 
with 
neurohumoral 
blockers 
(e.g. 
renin-angiotensin 
system 
blockers, 
sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists) may be continued 
at the same or lower dosage at the discretion of the treating physician, until the end of the 
treatment phase (max 4 days) or until complete decongestion is achieved, whatever comes first. 
Dose increases for any of these medications are not allowed during the screening and treatment 
phase with the exception of mineralocorticoid receptor antagonists in case of hypokalemia despite 
intravenous potassium supplement. In addition, starting an SGLT2 inhibitor and a switch from renin-
angiotensin system blockers to sacubitril/valsartan is not allowed during the screening and 
treatment phase, but might be pursued after decongestion is achieved. After decongestion, it is 
strongly recommended to up-titrate doses of neurohumoral blockers according to the guidelines in 
the HFrEF patients. Dosages of neurohumoral blockers are collected at screening, at discharge and 
at three months follow-up.  
 
4.3.4 
Randomisation and blinding 
The ADVOR study is a randomized double blind clinical trial with 2 treatment arms; therapy with 
high-dose loop diuretics and placebo vs therapy with high-dose loop diuretics and acetazolamide. 
An automated web-based system is used to randomly assign patients in a 1:1 ratio with variable 
blocks sizes, stratified for LVEF according to study centre. To ensure an equal proportion of HFpEF 


 
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versus HFrEF patients in both study arms, the population will be stratified at inclusion according to 
LVEF ≤40% versus >40%. Permuted block randomization according to centre and LVEF stratum will 
be used to achieve this.  
 
Patient, site personnel, sponsor personnel and data analysts will remain blinded to the identity of 
the treatment from the time of randomization until database lock. Though we do not foresee 
serious adverse events related to the study drug, the study code should only be broken for valid 
medical or safety reasons e.g. in the case of a severe adverse event where it is necessary for the 
investigator or treating health care professional to know which treatment the patient is receiving 
before the participant can be treated.  
Following rules apply for unblinding; 
- 
Rapid unblinding of a patient can be performed by a physician of the study team. 
Detailed information concerning the unblinding procedures is provided in the Manual of 
Operations.  
- 
On receipt of the treatment allocation details, the PI or treating health care professional 
will continue to deal with the participant’s medical emergency as appropriate. 
- 
The PI/Investigation team documents the breaking of the code and the reasons for doing 
so on the medical notes and eCRF. It will also be documented at the end of the trial in 
any final study report and/or statistical report. 
 
Unblinded data are to be kept strictly confidential until the time of unblinding of the trial and will 
not be accessible by anyone else involved in the trial with the following exceptions: (1) the Project 
Manager of the company responsible for the labelling and packaging of the IMP, (2) the IRT system 
programmers who work on the randomization and drug management system; and (3) the data 
manager who prepares reports required for regulatory reporting (suspected unexpected serious 
adverse reactions [SUSAR] reporting). These individuals will not be involved in the day-to-day 
running of the study. 
 
4.4 
Endpoint adjudication 
Because the primary endpoint requires physical examination of the blinded study physician, 
adjudication of the primary event is not possible. However, all admission labelled as HF readmission, 
all-cause mortality and the need for renal replacement therapy will be adjudicated by the Endpoint 
Adjudication Committee (EAC)  
 
For the endpoints HF readmission, all-cause mortality and the need for renal replacement therapy  a 
complete endpoint package will need to be send to the sponsor. This package should include 
anonymized source documents (SDs) relevant to the endpoint reported (e.g. discharge letter, 
emergency room notes, etc). The SD should include at least the reason for admission/death and the 
received treatment for the event (if applicable). This package will be assessed by the Endpoint 
adjudication members of the Endpoint adjudication committee.  
 
In case of discrepancy between the evaluation of the EAC members regarding the same event, the Trial 
Data Manager will contact the EAC members to inform them on the discrepancies found so the both 
of them can come to a final decision. The discrepancies and the final decision will be documented. 
 


 
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4.5 
Sample Size 
The ADVOR study is powered for primary endpoint which is the most relevant endpoint with respect 
to the study hypothesis and reliable data from large randomized clinical trials are available to make a 
formal power calculation.  
In the DOSE trial, which recruited a similar study population as targeted in the ADVOR study, successful 
decongestion with a similar definition was approximately 11% vs 18% after 72 h in the low vs high-dose 
loop diuretics arm. The high-dose loop diuretics arm of the DOSE trial is quite comparable to the 
standard of care group in the ADVOR study as the loop diuretic dose used in the latter is only slightly 
lower (2x instead of 2.5x the oral maintenance outpatient dose) and non-loop diuretics, which were 
infrequently used in the DOSE trial, are not allowed. Because of these slight differences, 15% is chosen 
as an estimate for occurrence of the primary endpoint in the monotherapy with high-dose loop 
diuretics (SOC) group. 
 
No reliable data are available from large clinical trials to estimate occurrence of the primary endpoint 
in the acetazolamide arm of the ADVOR study. Therefore, after thorough discussion with the advisory 
board a success rate of 25% was chosen, which represents a clear meaningful benefit of 10% more 
patients with appropriate decongestion after 72 h. Using both estimates, considering a type I error 
rate α=0.05 and type II error rate β=0.20 (yielding a statistical power of 80%), the targeted sample size 
for the ADVOR study is calculated at n = 494. A 5% drop out has been calculated in order to estimate 
the total number of 519 patients to be enrolled in the study. 
 
5 STATISTICAL ANALYSIS 
5.1 
General principles 
This statistical analysis plan dated 17 January 2022 is based on the statistical information documented 
in the study protocol version 2.0 dated 03 January 2019 (see section 10), the methods paper published 
in the European Journal of Heart Failure (2018)3 and guidance by the European Medicines Agency 
(EMA)4 and the Food and Drug Administration5 regarding the management of clinical trials during 
COVID-19 pandemic (2021). 
 
The scope of this statistical analysis plan is to outline the statistical tools used for the primary and 
secondary objectives of the ADVOR study following the procedures documented in the study protocol 
version 2.0 dated 03 January 2019 in all participating centres.  
 
Prior to the statistical analysis the collected study data will be cleaned by the data management team 
of the Clinical Trial Unit at the Ziekenhuis Oost-Limburg (ZOL-CTU). The cleaning will be performed 
according to the Data Management Plan agreed for the ADVOR trial.  
 
All statistical hypothesis are 2-sided and a 5% significance level will be used.  A correction for multiple 
testing will not be implemented.  
 
Trial results will be reported according to the CONSORT statement on reporting randomized controlled 
trials.  
For the analysis of the primary outcome, each secondary and exploratory outcome the following 
information will be presented: 
- 
the number of patients included in each analysis, by treatment arm  
- 
a summary statistic of the outcome (e.g. number (%), mean (SD)), by treatment arm  


 
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- 
the estimated treatment effect  
- 
a 95% confidence interval for the estimated treatment effect  
- 
A two-sided p-value for all analyses, a significance level of 5% will be used. 
 
All statistical analysis will be done with Statistical Analysis System (SAS) for Windows, SAS 9.4. 
5.2 
Interim analyses 
No interim analysis is planned regarding the ADVOR study. 
 
5.3 
Multiplicity adjustment 
There will be no correction for multiplicity of testing as there is only one primary endpoint. All other 
endpoints and subgroup analyses will be considered as exploratory. 
 
5.4 
Blind review 
Once the database is cleaned the dataset will be locked and transferred to  an independent academic 
statistical center (DSI/CenStat - University Hasselt) for efficacy and safety analysis according to the  
statistical analysis plan  
 
5.5 
Data sets to be analysed 
For the primary endpoint the statistical analysis will be based on an intention-to-treat analysis set 
(ITTAS) including all randomized patients.  Patients will be analysed according to the treatment group 
they were allocated to according to the electronic randomization system (irrespective of the actual 
treatment received).  
 
For the secondary endpoints the statistical analyses will be based on the same data set as will be used 
for the primary endpoint analysis.  
 
For the safety endpoints, all patients that were randomized and received at least 1 dose of the 
investigated drug or placebo will be included (safety population). For the safety analysis, patients will 
be grouped based on the actual study treatment received.  
 
5.6 
Subject disposition 
After closing of the database, a CONSORT diagram will be produced for transparent status of the 
subject reporting. 
 
5.7 
Violations and deviations 
The important protocol deviations listed below will be summarised by randomized treatment group 
- 
Patients who were randomized but did not meet inclusion and exclusion criteria 
- 
Patients who received study treatment with a wrong treatment vial number at any time during 
the study 
- 
Patients who received only acetazolamide/placebo but no loop diuretics on day 1, 2 or 3 






 
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The treatment effect for the primary endpoint is evaluated by means of a generalized linear mixed 
model, including a fixed treatment effect and random centre effect.  As a sensitivity analysis, the 
model will be extended by including a fixed effect (binary) indicating if the endpoint was assessed 
before or after the first identified COVID-19 case in Belgium dated 03 February 2020 and the 
interaction term between this variable and treatment. 
 
5.11 Analysis of secondary outcomes 
All statistical models implemented for the analysis of the secondary outcomes are mixed-effects 
models, including a fixed treatment effect and random centre effect. For the outcomes measured at 
multiple time points also random patient effects (intercept, slope) are included.  
 
5.11.1 Secondary outcome 1 
The combined endpoint of all-cause mortality and HF readmission during 3 months of follow-up, 
will be analysed as a binary and as a time-to-event endpoint.  
 
- 
For descriptive purposes, the number (%) of failure and success for the combined 
outcome of all-cause mortality and HF readmission during 3 months of follow-up will be 
given per treatment arm.  To investigate the treatment effect on the occurrence of the 
combined endpoint, a generalized linear mixed model for a binary outcome will be 
employed.  The model will incorporate a fixed treatment effect and random centre 
effect.  The results of this model will be presented as odds-ratio, 95% confidence interval 
and the associated p value.  
 
If the treatment effect on the composite endpoint of ‘all-cause mortality and HF 
readmission’ turns out to be statistically significant, both components will be evaluated 
separately in a hierarchical fashion with HF readmissions first and all-cause mortality 
second. For this analysis, HF readmission will include patients dying from any cause 
during the 3 months of FU.  The treatment effect, on the components, will be 
investigated by the same statistical model as used for the combined endpoint. 
 
- 
To investigate the treatment effect on the time until combined endpoint of all-cause 
mortality and HF readmission during 3 months of follow-up a survival analysis will be 
performed. Time to event is defined as the time between day 1 and the date of (first) HF 
readmission or death if there was no HF readmission. The analysis will be censored at 3 
months of follow-up or at the time when the patient was last known to be alive (for 
patients that withdraw or are lost to follow up), whichever occurs earlier.  Survival times 
will be summarised descriptively using Kaplan-Meier survival curves. Formal testing for 
a difference in time to event will be done using a mixed-effect Cox proportional hazard 
model including the treatment arm and a random centre effect (ie, using a shared frailty 
model). The proportional hazards assumption will be verified by plotting log cumulative 
hazard versus log-time for the intervention and SOC group. Model validity will be further 
explored using plots of Cox-Snell and Martingale residuals. The treatment effect will be 
summarised as the hazard ratio (HR), 95% CI and associated p value.  
 
 
 


 
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To assess whether the treatment effect differs according subgroups defined on the basis of LVEF 
(see table in section 5.10.2) a subgroup analysis will be performed. The statistical model formulated 
for the analysis of this endpoints (binary and time to event version) will be extended to include a 
fixed effect for the subgroup and an interaction term between the study arm and the subgroup. 
The interaction term will be considered significant at the 5% level. Within each subgroup, summary 
statistics of the outcome by treatment arm will be presented; the OR/HR for the treatment effect 
and 95% confidence interval.  A p-value for the interaction test will also be reported.  
 
5.11.2 Secondary outcome 2 
For each treatment arm mean, median and interquartile range for length of index hospitalization 
will be presented for patients who survived to hospital discharge.   The effect of treatment on length 
of index hospitalization, for patients who survived to hospital discharge,  is compared among 
treatment arms with a linear mixed model8 (fixed treatment effect and random centre effect). A log 
transformation will be employed as the model assumptions (such normality) will likely be violated. 
Model assumptions will be investigated by means of diagnostic plots. The results of this model will 
be presented as (geometric) mean length of index hospitalization (and 95% CI) per treatment group, 
the geometric mean ratio (GMR), 95% CI and associated p value.  
 
To assess whether the treatment effect differs according subgroups defined on the basis of LVEF 
(see table in section 5.10.2) a subgroup analysis will be performed. The statistical model formulated 
for the analysis of this endpoint will be extended to include a fixed effect for the subgroup and an 
interaction term between the study arm and the subgroup. The interaction term will be considered 
significant at the 5% level. Within each subgroup, summary statistics of the outcome by treatment 
arm will be presented; the GMR for the treatment effect and 95% confidence interval.  A p-value 
for the interaction test will also be reported.  
 
5.11.3 Secondary outcome 3 
The QoL scores (EQ-5D total score and EQ-VAS)  will be presented using line plots for each study 
arm to illustrate trends over time.  Depending on the distribution of the data, the means and 95% 
CI of means or medians and inter-quartile ranges at baseline, the morning of day 4 or discharge 
(whatever comes first), and at 3 months of follow up will be reported. Evolution in the QoL will be 
investigated via a linear mixed model, with the Qol score of morning of day 4 or discharge (whatever 
comes first), and 3 months follow up as the longitudinal dependent variable, with a fixed treatment 
effect, day, the interaction of treatment by day, and baseline QoL, random centre effect and 
random patient effect (intercept, slope) will be used. Model assumptions will be investigated by 
means of diagnostic plots. Transformation will be employed when the model assumptions (such 
normality) are violated.   
The analysis will be performed following the recommendations of the Belgian guidelines for health 
economic evaluation to value health care resource use will be used: 
https://kce.fgov.be/nl/een-belgische-waardenset-voor-de-eq-5d-5l-%E2%80%93-hoe-
gezondheidsgerelateerde-levenskwaliteit-waarderen  
 
A subgroup analysis with subgroups defined on the basis of LVEF, will also be performed. 
 






 
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Former (N,%) 
Current (N,%) 
Malignancy requiring 
chemo/radiotherapy 
No (N,%) 
Yes-past (N,%) 
Yes-current (N,%) 
Yes-past and current 
(N,%) 
MH_TUMORYN 
Nominal 
 
 
 
Weight (kg)  
VS_WGHT_D0 
Continue 
 
 
 
Pulse (beats/min)  
VS_PULSE_D0 
Continue 
 
 
 
Blood pressure (systolic) (mmHg) 
VS_BPS_D0 
Continue 
 
 
 
Blood 
pressure 
(diastolic) 
(mmHg) 
VS_BPD_D0 
Continue 
 
 
 
Mean Arterial Pressure (MAP) 
VS_MAP_D0 
Continue 
 
 
 
Congestion score 
VOA_SCORE_D0 
Ordinal 
 
 
 
Laboratory values 
Hematology (g/dL) 
Hematocrit (%) 
Sodium (mmol/L) 
Potassium (mmol/L) 
Chloride (mmol/L) 
Serum osmolality 
(mOsm/kg) 
Serum urea (mg/dL) 
eGFR (mL/min/1,73m2)
Total protein (g/L) 
Albumin (g/L) 
Fe (µg/dL) 
Ferritin (µg/dL) 
Transferrin saturation 
(TSAT) (%) 
LDH (U/L) 
Troponin (ng/L) 
NTproBNP/BNP 
LABB_HGB_D0, 
LABB_HT_D0, 
LABB_NA_D0, 
LABB_K_D0, 
LABB_CL_D0,  
LABB_OSM_D0, 
LABB_UREA_D0, 
LABB_GFR_D0, 
LABB_PROT_D0, 
LABB_ALB_D0, 
LABB_FE_D0, 
LABB_FERR_D0, 
LABB_TSAT_D0, 
LABB_LDH_D0, 
LABB_TROP_D0, 
LABB_BNPOPT_D0,  
LABB_BNP_D0  
 
Continue 
 
 
 
 
Diuretics 
Furosemide (mg) 
Thiazide (N,%) 
MRA (N,%) 
Report parent 
‘Screening’: 
DIU_TYPE + DIU 
DOSIS 
 
Report parent 
‘Screening’: 
DIU_TYPE 
Continue 
 
 
 
 
Nominal 
 
 
 
Neurohumoral blockers 
ACE (N,%) 
Beta-blocker (N,%) 
ARB (N,%) 
Entresto (N,%) 
Report parent 
‘Screening’: 
NH_TYPE 
Nominal 
 
 
 
Other concomitant medication 
Ivabradine (N,%) 
Hydralazine (N,%) 
Molsidomine (N,%) 
Isosorbide dinitrate, 
PO (N,%) 
Digoxin (N,%) 
Aspirin(N,%) 
NOAC/DOAC 
CONMED_OTHER_ 
D0 
Nominal 
 
 
 


 
Statistical Analysis Plan 
 
 
 
Document identification  
Version No: 2.0 
Version Date: 17MAR2022 
 
 
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VKA (N,%)  
P2Y12 (N,%) 
Statin (N,%) 
XO-inhibitor (N,%) 
Amiodarone (N,%) 
Flecainide (N,%) 
IV inotropes (N,%) 
IV vasodilators (N,%) 
Other anti-
hypertensive drugs 
(N,%) 
SGLT2-i (N,%) 
None (N,%) 
EQ-5D-5L  
(N, %) 
EQ-5D-5L score  
 
EQ5D_D0 
Report parent 
‘Screening’: 
EQ5D_MOBOPT, 
EQ5D_SCOPT, 
EQ5D_ACTOPT, 
EQ5D_PAINOPT, 
EQ5D_ANXOPT 
 
Nominal 
Continue 
 
 
 
EQ-5D-5L (VAS) 
(N,%) 
(0-100) 
EQ5D_SCORESL 
 
Continue 
 
 
 


 
Statistical Analysis Plan 
 
 
 
Document identification  
Version No: 2.0 
Version Date: 17MAR2022 
 
 
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8  REFERENCE 
 
1 Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, LeWinter MM, Deswal A, Rouleau 
JL, Ofili EO, Anstrom KJ, Hernandez AF, McNulty SE, Velazquez EJ, Kfoury AG, Chen HH, Givertz MM, 
Semigran MJ, Bart BA, Mascette AM, Braunwald E and O'Connor CM. Diuretic strategies in patients with acute 
decompensated heart failure. N Engl J Med. 2011;364:797-805.  
 
2 Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF 3rd, Feldman HI, Kusek JW, Eggers P, VanLente 
F, Greene T, Coresh J; CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). A new equation to 
estimate glomerular filtration rate. Ann Intern Med. 2009 May 5; 150(9):604-12 
 
3  Mullens, W., Verbrugge, F. H., Nijst, P., Martens, P., Tartaglia, K., Theunissen, E., Bruckers, L., Droogne, 
W., Troisfontaines, P., Damman, K., Lassus, J., Mebazaa, A., Filippatos, G., Ruschitzka, F., & Dupont, M. 
(2018). Rationale and design of the ADVOR (Acetazolamide in Decompensated Heart Failure with Volume 
Overload) trial. European Journal of Heart Failure, 20(11), 1591-1600. https://doi.org/10.1002/ejhf.1307.  
 
4 European Medicines Agency. Guidance on the management of clinical trials during the COVID-19 
(coronavirus) 
pandemic, 
version 
4, 
February 
04 
2021. 
https://ec.europa.eu/health/sites/default/files/files/eudralex/vol-10/guidanceclinicaltrials covid19 en.pdf  
(accessed January 14, 2022). 
 
5 US Food and Drug Administration. FDA guidance on conduct of clinical trials of medical products during 
COVID-19 public health emergency, August 2021. https://www.fda.gov/regulatory-information/search-fda-
guidance-documents/fda-guidance-conduct-clinical-trials-medical-products-during-covid-19-public-health-
emergency (accessed January 14, 2022).  
 
6 Kahan BC. Accounting for centre-effects in multicentre trials with a binary outcome - when, why, and how? 
BMC medical research methodology. 2014;14:20. 
 
7 Molenberghs, G. and Verbeke, G. (2005). Modelsfor Discrete Longitudinal Data. New York: Springer.  
 
8 Verbeke, G. and Molenberghs, F. (2000). Linear Mixed Models for Longitudinal Data. New York: Springer. 
                                                     


Summary of Changes 
 
 


 
 
Changes between original (V1.0) and final (V2.0) protocol: 
 
Amendment 
No. 
Protocol 
version no. 
Date issued 
Details of changes made 
01 
Version 2.0 
03 January 2019 
Cfr. explanation below. 
 
Details of changes made for amendment No. 01: 
 
- Clarification of maintenance dose of loop diuretics. To avoid any confusion, half of start dose given 
at randomization has been erased and we stated “1x orally daily maintenance dose”. 
- Clarification volume assessment scoring 
- If patients are being discharged earlier than day 4, parameters planned for the morning of day 4 will 
still be assessed but at discharge (i.e. EQ5D, NT-proBNP/BNP, blood samples for sub-study if 
applicable) 
- Removal of an endpoint event, i.e. rehospitalisation due to any cardiac event. 
- Clarification exclusion criteria:  
 Use of nitrates and/or molsidomine is allowed, but at the discretion of the treating physician 
instead of use of nitrates is allowed only when systolic blood pressure is above 140mmHg. 
 Treatment with acetazolamide within one month prior to randomization is not allowed 
instead of treatment with acetazolamide during the index hospitalisation before 
randomization. 
 Use of any non-protocol defined diuretic agent with the exception of mineralocorticoid 
receptor antagonists during the treatment phase of the study is not allowed instead of Use of 
any non-protocol defined diuretic agent with the exception of mineralocorticoid receptor 
antagonists. 
- Addition of one exclusion criteria: Subjects with urinary incontinence who are not willing to receive 
a bladder catheter 
- Collection of additional study data: 
 Use of iron per os and/or intravenously throughout the study will be recorded at discharge and 
at follow-up. 
 A predefined list of concomitant medication will need to be completed at discharge and at 3 
months follow-up (cfr. appendix 5) 
- Details concerning the collection of concomitant medication have been replaced by appendix 5. 
- Follow-up appointment will be 3 months (+ 14 days) after the start of study medication, instead of 
after hospital discharge. 
- For completeness, admission has been changed to screening.  
- Throughout the protocol, minor changes (e.g. typographical errors, clarifications, etc.) have been 
added. 
 
 
 


 
 
Changes between original (V1.0) and final (V2.0) Statistical Analysis Plan: 
 
Version number 
Version Date 
Author 
Reason for change 
Version 1.0 
17 January 2022 
ADVOR Scientific Study 
Team 
Liesbeth Bruckers 
(Statistician) 
First version 
Version 2.0 
17 March 2022 
ADVOR Scientific Study 
Team 
Liesbeth Bruckers 
(Statistician) 
Appendix A Baseline 
Characteristics: The Baseline 
Characteristics Iron PO and Iron 
IV mentioned in the Appendix A 
have been removed because 
these data will not be collected 
during the study.