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.