Door-to-Furosemide Time in Acute Heart Failure

Study Questions:

What is the association between time-to-diuretic treatment and clinical outcome in the acute phase in heart failure (AHF)?


The study authors conducted a prospective, multicenter, observational cohort study, the REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure), a study that aimed to assess the association between time to loop diuretic treatment and clinical outcome in patients with AHF admitted through the emergency department (ED). They defined door-to-furosemide (D2F) time as the time from patient arrival at the ED to the first intravenous furosemide injection. Patients with a D2F time <60 minutes were predefined as the early treatment group. The primary endpoint was all-cause in-hospital mortality. They performed univariable and multivariable logistic regression analyses to evaluate the association between early treatment and in-hospital prognosis. Propensity score matching was also performed as a sensitivity analysis to control for confounding.


The final cohort for analysis, after exclusion, included 1,291 AHF patients. In this cohort, the median D2F time was 90 minutes (interquartile range, 36-186 minutes), and 37.3% of the patients (n = 481) were categorized as the early treatment group. These patients were more likely to arrive by ambulance and had more signs of congestion compared with the nonearly treatment group. In-hospital mortality was significantly lower in the early treatment group (2.3% vs. 6.0% in the nonearly treatment group; p = 0.002). The earlier treatment remained significantly associated with lower in-hospital mortality (odds ratio, 0.39; 95% confidence interval, 0.20-0.76; p = 0.006) in multivariate analysis. The authors also found that the association between D2F time and in-hospital mortality might not be linear—in the first few hours after ED arrival, mortality steeply increased as D2F time was delayed, but this effect leveled off after approximately 100 minutes. Changing the time-window for patient inclusion from 24-48 hours did not change the results substantially (data not shown).


The authors of this paper concluded that early treatment with intravenous loop diuretics was associated with lower in-hospital mortality in patients presenting at the ED for AHF.


The results of this study demonstrating an association between D2F and in-hospital mortality are intriguing, but suggest that achieving euvolemia or dry weight rapidly may be desirable. Given that many patients with AHF also have renal dysfunction, further inquiry in this area will require assessment of both cardiac and renal biomarkers. Larger multicenter studies are needed to confirm these findings and to determine the mechanism for these effects. If these findings are confirmed, D2F may emerge as a quality measure.

Keywords: Biomarkers, Diuretics, Emergency Service, Hospital, Furosemide, Geriatrics, Heart Failure, Hospital Mortality, Prognosis, Sodium Potassium Chloride Symporter Inhibitors, Time-to-Treatment, Treatment Outcome

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