Table 2.

Current guidelines for combination diuretic therapy in acute heart failure

Professional Society	Level of Recommendation/Evidence	Recommendation
American Heart Association/American College of Cardiology/Heart Failure Society of America74 (2022)	Moderate recommendation Moderate-quality evidence	In patients hospitalized with heart failure when diuresis is inadequate to relieve symptoms and signs of congestion, it is reasonable to intensify the diuretic regimen using either higher doses of intravenous loop diuretics or addition of a second diuretic
European Society of Cardiology79 (2021)	Moderate recommendation Moderate-quality evidence	If the diuretic response remains inadequate despite doubling loop diuretic dose, concomitant administration of other diuretics acting at different sites, namely thiazides or metolazone or acetazolamide, may be considered
Canadian Cardiovascular Society80 (2017)	Weak recommendation Moderate-quality evidence	For patients with persistent volume overload despite optimal medical therapy and increase in loop diuretics, cautious additional use of a second diuretic (a thiazide/low-dose metolazone) may be considered