Contradicting studies on Door-to-diuretic time

    NextPrevious

    Contradicting studies on Door-to-diuretic time

    Hot off the press is a new study evaluating the effect of door-to-diuretic time on in-hospital mortality in patients presenting with acute heart failure. This study was closely modeled after a prior study by Matsue et al last year (reviewed in this pearl) that found that lasix administration within 60 minutes of ED arrival was associated with significantly decreased in-hospital mortality at 48 hours.

    This was a prospective observational cohort study of ~2,700 patients. Median time to diuresis was 128 minutes. Patients who received IV diuresis within 60 minutes (24%) had similar in-hospital mortality (5.0%) compared to patients with D2D time >60 minutes (5.1%). They also found no differences in 30-day or 1-year mortality (3% and 18.6%, respectively) between the 2 groups.

    This study had a number of advantages over the previous study, including:

    • evaluating total in-hospital mortality compared to the previous study, which only followed patient in-hospital mortality to the 48-hour mark
    • larger sample size
    • longer follow up periods looking at 30-day and 1-year mortality

    Given that heart failure is typically a more subacute presentation, it makes sense that specific door-to-diuretic time may not affect mortality.  It does stand to reason, however, that treating CHF earlier rather than later may still result in shorter hospitalizations, an outcome neither study addresses.  With these contradictory findings, although it’s likely important to diurese patients in a timely manner, I won’t be racing against the clock to give lasix to all of my CHF patients until higher quality data is available.

     

    References:

    Park et al. JACC: Heart Failure March 2018. The Effect of Door-to-Diuretic Time on Clinical Outcomes in Patients With Acute Heart Failure.
    Matsue et al. JACC June 2017. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. 

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • renal handling of water

      If you were on a tea & toast diet, how much water would you need to drink before you develop hyponatremia? I haven’t seen anyone work out the numbers before so here are my calculations. AndRead more

    • acute acidemia physiology

      As alluded to in the first post, don’t be fooled by a “normal” potassium in the setting of DKA because osmotic diuresis and H+/K+ exchange means that total body potassium is actually LOW. You all knowRead more

    • renal handling of potassium

      the first symptom of hyperkalemia is death Earlier post covered temporizing measures to counter hyperkalemia — namely, intracellular shift, increasing cardiac myocyte threshold potential. Give furosemide if the patient still urinates and consider dialysis, but then askRead more

    • bicarbonate revisited

      Previous post reviewed the safety of balanced crystalloids in hyper K. But what was up with serum bicarbonate decreasing with saline administration? This post introduces a new way of looking at the anion gap to possiblyRead more

    • hyperkalemia and balanced crystalloids

      Is it safe to give LR or plasmalyte to a hyperkalemic patient (these balanced crystalloids have 4-5 mEq/L K as opposed to 0 mEq/L K in normal saline)? Postponing the discussion of renal handling of potassium toRead more

    • hyperkalemia physiology

      You’ll likely encounter hyperkalemia on your next Resus / Cardiac shift, and you’ll instinctively treat it. But take a moment to review the fascinating physiology behind the “cocktail”! First, consider how K+ is buffered byRead more

    • Slow down your tachycardia (but not really)

      You’re sitting in resus bemoaning the departure of your most beloved attending when suddenly a patient wheels in without warning. The patient looks relatively stable but the triage RN tells you her heart rate wasRead more

    • Otitis externa: use the ear wick!

      Acute otitis externa (AOE) is a common complaint seen in pediatric as well as adult emergency departments. AOE is typically not accompanied by acute otitis media, although concurrent cases are possible. Also called “swimmer’s ear”Read more

    NextPrevious