Door-to-diuretic time has little impact on mortality for acute heart failure patients
The speed with which IV diuretics were administered to people with acute heart failure (AHF) didn’t appear to make a difference in short- or intermediate-term mortality rates, according to a study of 2,761 Korean patients.
Lead researcher Jin Joo Park, MD, and colleagues studied individuals from the Korea Acute Heart Failure registry who received IV diuretic agents within 24 hours of arriving to an emergency department. They used a one-hour cutoff point to define “early” versus “delayed” diuretic administration, with 24 percent of patients belonging to the early group.
Diuretics help clear congestion in patients presenting with AHF and have become a cornerstone of treatment, Park et al. noted. Furthermore, “time to therapy” is considered an important goal for other interventions, particularly percutaneous coronary intervention to treat ST-segment elevation myocardial infarction (STEMI).
But in this study, the morality differences between early and delayed diuretic initiation were insignificant across three different time periods. In-hospital mortality was 5.0 percent in the early group versus 5.1 percent in the delayed, while post-discharge one-month (4.0 versus 3.0 percent) and one-year (20.6 versus 19.3 percent) mortality rates were also similar. The neutral relationship between door-to-diuretic time and mortality remained after propensity-score matching and for four different subgroup analyses.
“In contrast to patients with STEMI, where acute occlusion of a coronary artery and the following ischemia lead to irreversible myocardial injury within a short time period (‘time is myocardium’), AHF is a ‘subacute’ process with a remote trigger and successive decompensation leading to hemodynamic and clinical congestion,” Park and coauthors wrote in JACC: Heart Failure. “Considering the reversibility of congestion and the relatively long time period between the trigger and full-blown AHF, the door-to-diuretic (D2D) time may have limited clinical impact on clinical outcomes.”
The researchers noted some important limitations to their work, namely the observational design of the study and the fact that only East Asians were included, limiting the generalizability to other groups.
“Given the nature of the study design, the study results are at best hypothesis generating, and the effect of D2D time on clinical outcomes must be confirmed in successive confirmatory studies,” they wrote.
In an accompanying editorial, two researchers identified three conditions an intervention must meet for time to treatment to be a crucial component of care: common treatment targets for most patients, a sufficiently understood pathophysiology and a window of opportunity during which “timely intervention interrupts or reverses ongoing tissue injury or damage before such damage becomes irreversible.”
Acute MI meets these conditions but AHF is more complicated in all three areas, noted G. Michael Felker, MD, MHS; and James L. Januzzi Jr., MD.
“The optimal treatment of acute heart failure remains uncertain with regard to both the importance of timing and the specific therapies likely to provide benefit,” the editorialists wrote. “The totality of available data, including the paper by Park et al., do not provide strong evidence for an important ‘time to treatment’ effect in acute heart failure. Although it certainly stands to reason that prompt diagnosis and initiation of therapy are part of efficient clinical care, the overriding consideration should remain ‘get it right’ rather than ‘do it fast.’”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.