Door-to-balloon time important in STEMI

General

Clinical Question:
Does time to reperfusion using coronary angioplasty ("door-to-balloon time") affect mortality rates?

Bottom Line:
Mortality resulting from ST-segment elevation myocardial infarction (STEMI) is independently related to the time it takes to administer percutaneous coronary intervention (PCI) following presentation to the emergency department. The relationship is still seen in patients who present several hours after symptoms begin. If you have a choice of hospitals, find out their door-to-balloon times and send patients to the faster one. (LOE = 2b)

Reference:
McNamara RL, Wang Y, Herrin J, et al, for the NRMI Investigators. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47:2180-2186.  [PMID:16750682]

Study Design:
Cohort (retrospective)

Setting:
Emergency department

Synopsis:
Faster use of thrombolytic therapy in the treatment of STEMI is associated with better outcomes, though this relationship is not as solid for PCI. The investigators conducting this study evaluated the role of speed of reperfusion therapy in a US registry. The registry contained data on 29,222 patients treated at 395 hospitals with PCI within 6 hours of presentation. The investigators excluded data from hospitals performing fewer than 20 PCIs over the 4 years of data collection. In-hospital mortality was associated with delays in treatment in a linear fashion with rates of 3.0%, 4.2%, 5.7%, and 7.4% at less than 91 minutes, 91 to 120 minutes, 121 to 150 minutes, and greater than 150 minutes, respectively (P <.01). In other words, 1 additional death is avoided for every 23 patients treated within 90 minutes rather than after 150 minutes. This trend was seen regardless of the time between symptom onset and presentation to the hospital. Faster administration of PCI was associated with improved outcomes in patients with at least one risk factor for STEMI, but not for patients with no risk factors.

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