Will [door-to-furosemide] become the next quality measure in modern HF care? Though one could understand enthusiasm to do so ….
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”