When would you consider using acetazolamide to augment diuresis in patients with ADHF?

The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating sub-optimal diuresis to a high dose of a loop diuretic (e.g. 2.5 X compared to the home baseline dose). I personally look for elevation in Bicarb levels in response to a loop diuretic and it has been d...