Randomized Controlled Trial of urinE chemiStry Guided aCute heArt faiLure treATmEnt (ESCALATE)

Inclusion Criteria:

• Age > 18

• Emergency Department diagnosis of Acute Heart Failure (AHF)

• Any one of the following: i. Chest radiograph or lung ultrasound consistent with AHF ii. Jugular venousdistension iii. Pulmonary rales on auscultation iv. Lower extremity edema v. S3gallop

• > 10 pounds of volume overload physician estimate or historical dry weight

• IV diuretic ordered or planned to be during first 24 hours of ED or inpatient stay

Exclusion Criteria:

• End Stage Renal Disease (ESRD) requiring dialysis

• Need for immediate intubation

• Acute Coronary Syndrome - presentation consistent with myocardial ischemia AND newST-Segment elevation/depression

• Temperature > 100.5ºF

• End Stage Heart Failure: transplant list or ventricular assist device

• Concurrent use of ototoxic medications including intravenous aminoglycosides andcisplatin

• Systolic Blood Pressure < 90 mmHg at time of consent

• LV outflow obstruction, severe uncorrected stenotic valvular disease or severerestrictive cardiomyopathy

• Greater than 2 doses of IV diuretic administered at the time of screening from thetime of the hospital presentation leading to this admission (outside hospital timeis included)

• Severe, uncorrected serum electrolyte abnormalities at the time of consent (serumpotassium <3.0 mEq/L, magnesium <1.0 mEq/L or sodium <125 or >150 mEq/l)

• Lack of informed consent