Acetazolamide for acute heart failure: rethinking clinical and economic value in a field of narrow gains

This invited editorial refers to ‘Cost-effectiveness and budget-impact analysis of Acetazolamide in decompensated heart failure patients with volume overload in the German health care system’, by V. Castiglione et al., https://doi.org/10.1093/ehjqcco/qcaf140. Acute decompensated acute heart failure (ADHF) remains one of the most resource-intensive syndromes in cardiovascular medicine. Globally, HF is among the leading causes of hospitalization and consumes a disproportionate share of healthcare expenditure, largely owing to recurrent admissions and prolonged length of stay in an ageing, comorbid population.1 Persistent congestion at discharge is common and strongly predicts early rehospitalization and mortality, yet pharmacological innovation in the acute setting has lagged behind the remarkable advances achieved in chronic HF.2 Numerous trials testing novel intravenous therapies or early initiation of disease-modifying agents have shown neutral or modest benefits. Most recently, the DAPA ACT HF–TIMI 68 trial reported no significant reduction in cardiovascular death or worsening HF at 60 days with in-hospital initiation of dapagliflozin.3