Dapagliflozin vs. Acetazolamide in Patients With Acute Heart Failure: A Randomized Controlled Trial ( CHOICE ‐ AHF )

Early adjunctive therapies may improve decongestion and symptoms in acute heart failure. This trial compared dapagliflozin with acetazolamide when initiated early, focusing on dyspnea relief as the primary outcome and decongestive, diuretic, natriuretic, and safety outcomes. In this randomized, active-controlled trial, 108 adults hospitalized with acute heart failure, dyspnea, and objective evidence of congestion requiring intravenous loop diuretics were randomized to receive dapagliflozin 10 mg (N = 55) or acetazolamide 500 mg (N = 53) once daily for 3 days alongside standard care. The primary endpoint was the between-group difference in 72-hour dyspnea visual analog scale area under the curve. Secondary endpoints included successful decongestion within 3 days, diuretic and natriuretic responses, the relative change in N-terminal pro-B-type natriuretic peptide levels from baseline to day 3, and safety. Acetazolamide produced a significantly lower 72-hour dyspnea area under the curve than dapagliflozin (2647.9 ± 1213.8 vs. 2988.7 ± 1196.7 mm × hour; P = 0.048). It increased cumulative urine output over 72 hours (12,200 vs. 10,000 mL; P = 0.019) and total natriuresis over 48 hours (824.7 vs. 547.9 mmol; P = 0.001). Dapagliflozin achieved a larger reduction in N-terminal pro-B-type natriuretic peptide at 72 hours (-34.2% vs. -25.0%; P = 0.003). Safety events were infrequent and similar. In conclusion, acetazolamide provided greater dyspnea relief, diuresis, and natriuresis, whereas dapagliflozin produced a larger short-term reduction in N-terminal pro-B-type natriuretic peptide. Further studies are needed to validate these findings. Trial registration: https://clinicaltrials.gov/study/NCT06783166.