Elsevier

Progress in Cardiovascular Diseases

Volume 58, Issue 3, November–December 2015, Pages 230-240
Progress in Cardiovascular Diseases

Door to Balloon Time: Is There a Point That Is Too Short?

https://doi.org/10.1016/j.pcad.2015.09.002Get rights and content

Abstract

The duration of ischemic time is directly related to permanent myocardial damage and mortality in the setting of ST-elevation myocardial infarction (STEMI). Rapidly restoring myocardial blood flow to limit the total ischemic time is a priority. The time duration between a patient entering the medical system and being treated with percutaneous coronary intervention to open the occluded culprit vessel is termed door-to-balloon (DTB) time, which is publicly reported and used to judge hospital quality of care. While longer DTB time is associated with increased mortality in the setting of STEMI, efforts to lower DTB time have not translated into decreased mortality. Here we review the literature on DTB time, explore the factors thought to influence the interpretation of the association between DTB time and mortality, and make suggestions on goals for future efforts related to DTB time.

Section snippets

Defining the ischemic phase

The extent of myocardial damage is directly related to the duration of myocardial ischemia.6 The benefit of restoring blood flow is greatest when it occurs early, prior to irreversible myocyte necrosis. From a clinical perspective, total ischemic time can be thought of as two segments: (1) the time between symptom onset (roughly representing the onset of myocardial ischemia) and when a patient enters the medical system, and (2) the elapsed time from patient presentation to when myocardial blood

DTB time: a chronological perspective

The importance of rapid reperfusion for STEMI was described initially in the context of thrombolytic therapy, which is meant to dissolve thrombus within the occluded coronary artery. The mortality benefit of thrombolysis for STEMI is dependent on the time from symptom onset to treatment, as described in the revolutionary studies of thrombolytics.7., 8. When thrombolytics were administered early after symptom onset, the associated mortality was lower.7., 8., 9. Longer time (> 4 h) from symptom

Reduction in DTB times

With the literature supporting the idea that longer DTB time was associated with increased mortality, it was extrapolated that lowering DTB time could reduce the mortality rate for STEMI. Strategies were developed to coordinate medical systems for rapid triage of patients with STEMI for PCI within minutes of hospital arrival. Key stakeholders including the ACC and AHA launched programs such as the Door-to-Balloon (D2B) Alliance and Mission: Lifeline in order to further the goal of achieving

Global efforts to improve outcomes for STEMI

Internationally, there are variations in preference of reperfusion strategy for STEMI (PCI vs. fibrinolysis) and timeliness of treatment. Many countries have initiated registries to track and report on treatments and outcomes for STEMI.27., 28., 29., 30. As quality improvement efforts require commitment of resources, this is a greater challenge in middle and low-income nations. Minimizing ischemic time requires a complex choreography of events that is difficult even under the most optimal

Correlating improvements in DTB time with mortality

In the US, evaluating the outcome of efforts to lower DTB time has been a priority. It is exemplary that the D2B Alliance was able to consolidate the support of a variety of stakeholders to affect a quality improvement initiative as vast as D2B. Studies on trends in DTB time have consistently demonstrated that DTB times have declined since the measure became a priority. From 1994 to 2006, median DTB time fell from 111 to 79 min in the National Registry of Myocardial Infarction (NRMI).39 There

Factors considered in reporting DTB times

Clinically there are legitimate indications to delay PCI after hospital arrival, such as to stabilize a patient who develops cardiac arrest in the ED, or when aortic dissection or intracranial hemorrhage needs to be ruled out prior to PCI. Other factors are within the scope of the cath lab team, including rapidly obtaining vascular access and quickly restoring blood flow to the culprit vessel. For publicly reported DTB time in the ACC initiative National Cardiovascular Data Registry (NCDR)

DTB time as a quality measure

As reimbursement moves toward pay-for-performance strategies, there has been increasing pressure on hospitals to provide timely and high quality care. DTB times are easily calculated, and STEMI is a common reason for hospital admission. Currently, patients can review the proportions of patients meeting the DTB goal for hospitals in their area.37 The index is promoted to patients as a measure of “how often hospitals provide care that research shows gets the best results for patients.” As the

Goals for the future

Lowering DTB time limits the total ischemic time. Attempting to lower the total ischemic time in the setting of STEMI should continue to be a priority, including promoting reductions in symptom onset to presentation. Globally, there is much to be gained, especially in countries with a high percentage of patients who do not receive any reperfusion therapy, and in countries where there are long delays from symptom onset or first medical contact to treatment.27 Subgroups most likely to benefit

Statement of Conflict of Interest

There are no relevant relationships or conflicts to disclose.

References (55)

  • E.H. Bradley et al.

    National efforts to improve door-to-balloon time results from the Door-to-Balloon Alliance

    J Am Coll Cardiol

    (2009)
  • K.F. Alhabib et al.

    Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: results of the Saudi Project for Assessment of Coronary Events (SPACE) registry

    J Saudi Heart Assoc

    (2011)
  • R.J. Goldberg et al.

    Prehospital delay in patients with acute coronary syndromes (from the Global Registry of Acute Coronary Events [GRACE])

    Am J Cardiol

    (2009)
  • C.M. Gibson et al.

    Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006

    Am Heart J

    (2008)
  • W.J. Rogers et al.

    Trends in presenting characteristics and hospital mortality among patients with ST elevation and non-ST elevation myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

    Am Heart J

    (2008)
  • R.H. Mehta et al.

    Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention: incidence, predictors, and outcomes

    J Am Coll Cardiol

    (2004)
  • R.H. Mehta et al.

    Prognostic significance of postprocedural sustained ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention (from the HORIZONS-AMI Trial)

    Am J Cardiol

    (2012)
  • S.G. Ellis et al.

    The weasel clause: excluding patients from door-to-balloon analyses

    J Am Coll Cardiol

    (2010)
  • F.A. Masoudi et al.

    ACC/AHA 2008 statement on performance measurement and reperfusion therapy: a report of the ACC/AHA Task Force on Performance Measures (Work Group to Address the Challenges of Performance Measurement and Reperfusion Therapy)

    J Am Coll Cardiol

    (2008)
  • H.S. Gurm et al.

    Eroding the denominator: the incomplete story of door-to-balloon time reporting

    J Am Coll Cardiol

    (2012)
  • B.K. Nallamothu et al.

    Comparing hospital performance in door-to-balloon time between the Hospital Quality Alliance and the National Cardiovascular Data Registry

    J Am Coll Cardiol

    (2007)
  • F.A. Masoudi et al.

    Cardiovascular care facts: a report from the national cardiovascular data registry: 2011

    J Am Coll Cardiol

    (2013)
  • J.C. Blankenship et al.

    Door-to-balloon times under 90 min can be routinely achieved for patients transferred for ST-segment elevation myocardial infarction percutaneous coronary intervention in a rural setting

    J Am Coll Cardiol

    (2011)
  • A.S. Go et al.

    Heart disease and stroke statistics—2014 update: a report from the American Heart Association

    Circulation

    (2014)
  • M.T. Roe et al.

    Quality of care by classification of myocardial infarction: treatment patterns for ST-segment elevation vs non-ST-segment elevation myocardial infarction

    Arch Intern Med

    (2005)
  • R.W. Yeh et al.

    Population trends in the incidence and outcomes of acute myocardial infarction

    N Engl J Med

    (2010)
  • America's hospitals: improving quality and safety. Vol...
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