Combining hypertonic saline with high dose loop diuretics in acute decompensated heart failure has the potential to enhance diuresis, cardiac contractility and improve heart failure morbidity and mortality. The potential mechanism involves improvements in both renal and coronary blood flow. A recent meta-analysis suggests that the use of hypertonic saline plus a loop diuretic in decompinsated acute heart failure could lead to improved heart failure outcomes. However, larger randomized clinical studies are needed.