Will [door-to-furosemide] become the next quality measure in modern HF care? Though one could understand enthusiasm to do so ….
No.
No one would understand such enthusiasm, despite the hopeful soaring rhetoric of the editorial accompanying this article. That enthusiasm will never materialize.
The thrills stacked to the ceiling here are based on the data in the REALITY-AHF registry, a multi-center, prospective, observational cohort designed to collect data on treatments administered in the acute phase of heart failure treatment in the Emergency Department. Twenty hospitals, mixed between academic and community, in Japan participated. Time-to-furosemide, based on the authors’ review of prior evidence, was prespecified as particular data point of interest.
They split their cohort of 1,291 analyzed patients between “early” and “non-early” furosemide administration, meaning within 60 minutes of ED arrival and greater than 60 minutes. Unadjusted mortality was 2.3% in the early treatment group and 6% in the non-early – and similar, but slightly smaller, differences persisted after multivariate adjustment and propensity matching. The authors conclude, based on these observations, the association between early furosemide treatment and mortality may be clinically important.
Of course, any observational cohort is not able to make the leap from association to causation. It is, however, infeasible to randomize patients with acute heart failure to early vs. non-early furosemide – so this is likely close to the highest level of evidence we will receive. As always, any attempt at adjustment and propensity matching will always be limited by unmeasured confounders, despite incorporating nearly 40 different variables. Finally, patients with pre-hospital diuretic administration were excluded, which is a bit odd, as it would make for an interesting comparison group on its own.
All that said, I do believe their results are objectively valid – if clinically uninterpretable. The non-early furosemide cohort includes both patients who received medication in the first couple hours of their ED stay, as well as those whose first furosemide dose was not given until up to 48 hours after arrival. This probably turns the heart of the comparison into “appropriately recognized” and “possibly mismanaged”, rather than a narrow comparison of simply furosemide, early vs. not. Time may indeed matter – but the heterogeneity of and clinical trajectory of patients treated between 60 minutes and 48 hours after ED arrival defies collapse into a dichotomous “early vs. non-early” comparison.
And this certainly ought not give rise to another nonsensical time-based quality metric imposed upon the Emergency Department.
“Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure”
“Finally, patients with pre-hospital diuretic administration were excluded, which is a bit odd, as it would make for an interesting comparison group on its own.”
EMS could be the antediluvian group, in more ways than one.
In EMS, we are terrified of giving boluses of NTG, which improve survival, regardless of blood pressure, but we are comfortable giving a drug that is based on a misunderstanding of pathophysiology and a lack of evidence.
Fortunately, prehospital use of Lasix is going away.
Maryland has removed furosemide from their protocols.
Furosemide has been taken out of the Pennsylvania EMS protocols. The 2016 protocols have it highlighted in yellow (to indicate that it is a change from the previous protocols) with a line drawn through the part about giving furosemide on a medical command order. Furosemide has been limited to being given only by medical command order for years, but that has been widely ignored by those who worship the magical traditional powers of furosemide.
The 2017 protocols do not include any mention of furosemide, but the required medication list does include furosemide. Maybe just a typographical oversight, but it may be that some of the old timers just can’t deal with reality and want their people to give a drug that works on organs blood is shunted away from. This way it takes effect after the other medication has caused the patient to improve to the point where there is no benefit from the furosemide and it results in an increase in the fluid depletion the patient already had. Why give furosemide? Tradition. “Reasoning will never make a Man correct an ill Opinion, which by Reasoning he never acquired.” Jonathan Swift.
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@RM – I thought of you smiling up at us when most of NYS removed furosemide from our most recent set of protocols and even the formulary. We can even give up to three nitros at a time for APE if the systolic’s > 200 mmHg. At least a decade since you started pushing for those changes, but it’s nice to actually enjoy using protocols now.
It’s very odd to have such a dichotomy – “time to furosemide matters” vs. “furosemide is not an important early treatment.”
Generally speaking, I think their time cut-off implies something other than what they conclude – and it just relates to making the appropriate diagnosis of a fluid-overload state in a reasonable acute time period, rather than some supposed benefit of empiric furosemide.