Author + information
- Takeshi Kitai, MD, PhD and
- Yuya Matsue, MD, PhD∗ ()
- ↵∗Department of Cardiology, Juntendo University School of Medicine and Cardiovascular Respiratory Sleep Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
We read with great interest the paper by Park et al. (1) on the prognostic impact of time to diuretics in the emergency department in patients with acute heart failure (AHF). The primary results of this study are discordant with those of previous reports and with the results of our recent study, which reported on the association between early diuretic treatment and better in-hospital outcomes from REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure) (2). Park et al. (1) should be congratulated on their very important work, which provides us with additional information on this clinically relevant topic.
In the study results, we found some differences between KorAHF Registry (Prospective Cohort for Heart Failure in Korea) and REALITY-AHF, besides the association between early diuretic treatment and in-hospital mortality. First, the median time to first intravenous diuretics was 128 min in the study by Park et al. (1), whereas it was much shorter in our study (2), at a median of 90 min. Consequently, only 25% of the study patients were treated with diuretics within 60 min of hospital arrival in KorAHF, whereas 38% of the study patients were treated within 60 min in REALITY-AHF. Second, predictors derived from multivariable analyses were not similar in these studies, and the only common factor was a history of atrial fibrillation. Third, REALITY-AHF was a study that specifically focused on the association between time to treatment and prognosis. By contrast, KorAHF was a registry whose 2 major objectives were as follows: 1) to describe patients’ characteristics, current treatments, and outcomes; and 2) to examine regional variation in comparison with registries from other countries (3).
What is the reason for the conflicting results among the studies, despite their similar study design, sample group (Asian population), and method of analysis? One possibility that should clearly be stated is whether KorAHF aimed to collect the data on “door to furosemide time” (D2F) a priori. In other words, was the D2F described in the protocol of KorAHF from the beginning? This point should be clarified because it is very difficult to collect data accurately in the emergency department, and the quality of data can be very easily impaired if researchers are not aware that data will be analyzed. If the D2F time was not announced as a variable of interest before the study was started and was subsequently collected, the analysis should be described as “retrospective” even though KorAHF itself is a prospective study. This is not simply a semantic issue, given the possibility that care providers could have administered intravenous furosemide to patients without immediately recording the time of injection, thereby increasing the D2F time (because it is unlikely to be shorter) and causing inaccuracies if they had not been aware of its importance.
In any case, our central hypothesis focuses on the potential contribution of rapid initial evaluation and prompt diagnosis leading to early effective treatment, not the pharmacological actions of diuretics per se. Undoubtedly, many factors can influence outcomes in AHF. Given the significant heterogeneity in the underlying pathophysiology and clinical phenotypes among patients with AHF, many aspects still remain to be elucidated to identify a more clinically effective acute phase treatment strategy for patients with AHF.
Please note: Dr. Matsue is affiliated with a department endowed by Philips Respironics, ResMed, Teijin Home Healthcare, and Fukuda Denshi; and has received an honorarium from Otsuka Pharmaceutical Co. Dr. Kitai has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
- Park J.J.,
- Kim S.H.,
- Oh I.Y.,
- et al.
- Matsue Y.,
- Damman K.,
- Voors A.A.,
- et al.