Door-to-Diuretic Time and Outcomes in Acute Heart Failure: A Scoping Review.

Introduction: Inadequate decongestion remains an unmet need in the management of patients with heart failure. The concept of door-to-diuretic (D2D) time to improve outcomes has been proposed for patients with heart failure (HF), but the trial results have been mixed.

Methods: We utilized Preferred Reporting Instrument for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) for scoping reviews with an extensive a priori search strategy for databases: PubMed and Scopus between January 2015 and November 2023. We used the key search terms "door-to-diuretic time" OR "door-to-furosemide time" OR "acute heart failure decongestion". Early D2D time was defined as intravenous (IV) diuretic administration within 30-120 min of patient arrival to the healthcare facility. Articles were included if they met our criteria, were written in the English language, and investigated door-to-diuretic or furosemide time as a decongestive strategy to improve outcomes in patients with acute HF.

Results: From 588 articles, 13 articles fulfilled the inclusion criteria after excluding duplicates and articles that did not meet our inclusion criteria. Of these studies, there was 1 meta-analysis and 12 observational cohort/registry-based studies (10 were positive trials and 2 were neutral). The most common outcomes examined were mortality and rehospitalization with early diuretic administration. First, early treatment was associated with lower in-hospital mortality and shorter hospital length of stay. Second, higher doses of furosemide were associated with improved HF symptoms and decreased hospitalization, at the cost of transiently worsening renal function. Third, the evidence is mixed for long-term mortality benefits.

Conclusion: Although the impact of early D2D time on HF outcomes is mixed, early diuretic administration appears to be an effective and safe strategy that warrants further investigation in large-scale pragmatic comparative effectiveness trials. Future trials should consider utilizing diuretic efficiency-guided dose escalation and augmented diuresis using high-dose or combination diuretic therapy.