Similarities and Distinctions Between Acetazolamide and SGLT2 Inhibitors in Patients With Acute Heart Failure: Key Insights Into ADVOR and EMPULSE

In two randomized controlled trials, the use of acetazolamide and sodium-glucose cotransporter 2 (SGLT2) inhibitors as adjunctive therapy to loop diuretics in acute heart failure did not show significant long-term benefits. While both drugs have the ability to inhibit sodium reabsorption, resulting in diuretic effects, the compensatory upregulation of sodium reabsorption at other sites in the kidney negates their sustained natriuretic effect. In the case of acetazolamide, it improved physical signs of fluid retention but did not produce natriuresis or impact morbidity/mortality. Empagliflozin, an SGLT2 inhibitor, showed limited effects on diuresis and physical signs of congestion but had some positive effects on health status and heart failure events. However, the magnitude and timing of these effects were similar to other SGLT2 inhibitors used in chronic heart failure trials. Therefore, the immediate diuretic effects of these drugs are unlikely to significantly influence the clinical outcomes of acute heart failure patients.