Early Sequential Nephron Blockade in Acute Heart Failure Patients: A Randomised, Controlled Study

Inclusion Criteria:

• Age ≥18 years

• Diagnosis of acute heart failure which is defined by 2 of the 3 following features: ≥2+ leg edema, jugular venous pressure >10 cm from physical examination or centralvenous pressure >10 mmHg, and bilateral pulmonary edema or bilateral pleural effusionfrom chest radiography

• Patients consent to participate into the study

Exclusion Criteria:

• Patients who receive furosemide ≥500 mg/day or hydrochlorothiazide ≥100 mg/day orspironolactone ≥100 mg/day or tolvaptan of any doses

• Patients who have systolic blood pressure <100 mmHg or who need vasoactive drugsinotropic agents (except dobutamine)

• Patients with intravascular volume depletion from clinical evaluation

• Patients with chronic kidney disease stage 5 (estimated glomerular filtration rate <15ml/min/1.73 m2) or patients who receive maintenance dialysis

• Patients who require renal replacement therapy at the time of admission

• Patients whom diagnosed hypertrophic obstructive cardiomyopathy, severe valvularstenosis or complex congenital heart disease

• Patients with sepsis or systemic infection

• Pregnant women

• Patients who have history of furosemide, spironolactone or hydrochlorothiazide allergy