Door-to-Diuretic Time in Acute Heart Failure

Study Questions:

What is the impact of door-to-diuretic (D2D) time on mortality in patients with acute heart failure (AHF) who were presenting to an emergency department (ED)?


The investigators included patients who received intravenous diuretic agents within 24 hours after ED arrival in the Korea Acute Heart Failure registry, which enrolled 5,625 consecutive patients hospitalized for AHF. Early and delayed groups were defined as D2D time ≤60 minutes and D2D time >60 minutes, respectively. The primary outcomes were in-hospital death and post-discharge death at 1 month and 1 year on the basis of D2D time. A multivariable logistic regression and Cox proportional hazards regression models were used to determine the independent effect of D2D time on in-hospital and post-discharge outcomes, respectively.


A total of 2,761 patients met the inclusion criteria. The median D2D time was 128 minutes (interquartile range, 63-243 minutes), and 663 (24%) patients belonged to the early group. The baseline characteristics were similar between the groups. The rate of in-hospital death did not differ between the groups (5.0% vs. 5.1%; p > 0.999), nor did the postdischarge 1-month (4.0% vs. 3.0%; log-rank p = 0.246) and 1-year (20.6% vs. 19.3%; log-rank p = 0.458) mortality rates. The Get With the Guidelines-Heart Failure risk score was calculated for each patient. In multivariate analyses with adjustment for Get With the Guidelines-Heart Failure risk score and other significant clinical covariates and propensity-matched analyses, D2D time was not associated with clinical outcomes.


The authors concluded that D2D time was not associated with clinical outcomes in a large prospective cohort of patients with AHF who were presenting to an ED.


This study reports that there was no difference in the in-hospital and post-discharge outcomes between AHF patients in the early and delayed diuretic groups. These findings contradict a previous study (REALITY-AHF), which reported that D2D time <60 minutes was associated with a 61% reduced risk for in-hospital mortality in patients with AHF presenting to the ED in Japan. Given two observational studies with discordant findings, the definitive effects of earlier diuretic therapy on outcomes need to be investigated in prospective randomized clinical studies.

Keywords: Diuretics, Emergency Service, Hospital, Heart Failure, Hospital Mortality, Outcome Assessment, Health Care, Patient Discharge

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