“Door-to-Furosemide Time” in Acute Heart Failure Patients

Summary and Comment |
July 27, 2017

“Door-to-Furosemide Time” in Acute Heart Failure Patients

  1. Kirsten E. Fleischmann, MD, MPH

Earlier diuretic initiation was associated with lower mortality. But why?

  1. Kirsten E. Fleischmann, MD, MPH

Guidelines recommend immediate treatment for patients presenting to the emergency department (ED) with acute heart failure (AHF), but is the time to diuretic initiation a strong predictor of outcome — or even a target akin to “door-to-balloon time” in ST-segment elevation myocardial infarction? In this analysis of a Japanese cohort, investigators assessed whether early diuretic initiation is associated with lower mortality.

Among 1291 patients with AHF who received loop diuretics (i.e., intravenous furosemide) within 24 hours of ED arrival, median time to diuretic therapy was 90 minutes, with 37% receiving loop diuretics within 60 minutes (the early group). Early-group patients were more likely to arrive by ambulance, to have higher blood pressures and heart rates, and to have more signs of congestion. Yet, in-hospital mortality was significantly lower in the early group than in the non-early group (2.3% vs. 6.0%); this difference persisted in multivariate and propensity-matched analyses.


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-group patients also had more obvious heart failure and pulmonary edema — indications known to respond well to treatment — which might lead to more favorable outcomes. At any rate, initiating diuretic therapy promptly when AHF is present seems wise.

Editor Disclosures at Time of Publication

  • Disclosures for Kirsten E. Fleischmann, MD, MPH at time of publication Leadership positions in professional societies American College of Cardiology and American Heart Association (Vice Chair, Writing Committee for Guidance on Cardiovascular Evaluation and Care for Noncardiac Surgery)


Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.