Key result
Early IV furosemide linked to ~61% lower in-hospital mortality versus delayed treatment.
Why the study?
AHF is a life-threatening disease requiring urgent treatment, including recommended immediate initiation of loop diuretics, but the association between time-to-diuretic treatment and clinical outcome required prospective evaluation.
Does early treatment with intravenous furosemide (<60 minutes) reduce in-hospital mortality in patients hospitalized with acute heart failure?
Cohort (n=1,291)
Yes
Does early treatment with intravenous furosemide (<60 minutes) reduce in-hospital mortality in patients hospitalized with acute heart failure?
Odds Ratio: 0.39 (95% CI 0.2–0.76)
Absolute Event Rate: 2.3% vs 6%
p-value: p=0.006
Early administration of intravenous loop diuretics (within 60 minutes of ED arrival) is associated with significantly lower in-hospital mortality in patients with acute heart failure.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Taking a little more time doesn't necessarily mean you're putting the patient in harm's way.”
“In this prospective multicenter, observational cohort study of patients presenting at the emergency department for acute heart failure, early treatment with intravenous loop diuretics was associated with lower in-hospital mortality.”
“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 furosemide was associated with lower in-hospital mortality; prospective trials are required before changing practice.
BACKGROUND: Acute heart failure (AHF) is a life-threatening disease requiring urgent treatment, including a recommendation for immediate initiation of loop diuretics. OBJECTIVES: The authors prospectively evaluated the association between time-to-diuretic treatment and clinical outcome. METHODS: REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) was a prospective, multicenter, observational cohort study that primarily aimed to assess the association between time to loop diuretic treatment and clinical outcome in patients with AHF admitted through the emergency department (ED). Door-to-furosemide (D2F) time was defined as the time from patient arrival at the ED to the first intravenous furosemide injection. Patients with a D2F time <60 min were pre-defined as the early treatment group. Primary outcome was all-cause in-hospital mortality. RESULTS: Among 1,291 AHF patients treated with intravenous furosemide within 24 h of ED arrival, the median D2F time was 90 min (IQR: 36 to 186 min), and 481 patients (37.3%) 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). In multivariate analysis, earlier treatment remained significantly associated with lower in-hospital mortality (odds ratio: 0.39; 95% confidence interval: 0.20 to 0.76; p = 0.006). CONCLUSIONS: In this prospective multicenter, observational cohort study of patients presenting at the ED for AHF, early treatment with intravenous loop diuretics was associated with lower in-hospital mortality. (Registry focused on very early presentation and treatment in emergency department of acute heart failure syndrome; UMIN000014105).
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Matsue et al. (2017) conducted a cohort in Acute heart failure (n=1,291). Early treatment with intravenous furosemide (door-to-furosemide time <60 min) vs. Nonearly treatment (door-to-furosemide time ≥60 min) was evaluated on all-cause in-hospital mortality (OR 0.39, 95% CI 0.20 to 0.76, p=0.006). Early treatment with intravenous furosemide (<60 min from ED arrival) was associated with lower in-hospital mortality compared to nonearly treatment (2.3% vs. 6.0%; OR 0.39, 95% CI 0.20-0.76).
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