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Guidelines recommend immediate treatment for patients presenting to the emergency department (ED) with acute heart failure (AHF), but is the time to diuretic initiation a strong predictor of outcome — or even a target akin to “door-to-balloon time” in ST-segment elevation myocardial infarction? In this analysis of a Japanese cohort, investigators assessed whether early diuretic initiation is associated with lower mortality.
Among 1291 patients with AHF who received loop diuretics (i.e., intravenous furosemide) within 24 hours of ED arrival, median time to diuretic therapy was 90 minutes, with 37% receiving loop diuretics within 60 minutes (the early group). Early-group patients were more likely to arrive by ambulance, to have higher blood pressures and heart rates, and to have more signs of congestion. Yet, in-hospital mortality was significantly lower in the early group than in the non-early group (2.3% vs. 6.0%); this difference persisted in multivariate and propensity-matched analyses.
Matsue Y et al. Time-to-furosemide treatment and mortality in patients hospitalized with acute heart failure. J Am Coll Cardiol 2017 Jun 27; 69:3042. (http://dx.doi.org/10.1016/j.jacc.2017.04.042)
Januzzi JL Jr and Felker GM.Door-to-furosemide therapy in the ED: New quality metric or just a piece of the puzzle? J Am Coll Cardiol 2017 Jun 27; 69:3052. (http://dx.doi.org/10.1016/j.jacc.2017.05.009)
Comment
In this nonrandomized study, AHF patients who received diuretics earlier did better. Editorialists argue that, although early therapy probably leads to more rapid decongestion, studies of other agents that also decongest (e.g., serelaxin, ularitide) have yielded mixed results; therefore, they postulate this is just part of the story. Early-group patients also had more obvious heart failure and pulmonary edema — indications known to respond well to treatment — which might lead to more favorable outcomes. At any rate, initiating diuretic therapy promptly when AHF is present seems wise.