Door to Balloon Time: Is There a Point That Is Too Short?
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.
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Cited by (11)
The Evolving Face of Myocardial Reperfusion in Acute Coronary Syndromes: A Primer for the Internist
2018, Mayo Clinic ProceedingsCitation Excerpt :Ongoing and upcoming trials will hopefully shed light on these contentious issues in ACS. There is a move to reevaluate the notion of door to balloon time and reframe the prerevascularization timing paradigm,56 noting the diminishing mortality returns despite improved door to balloon times.57 Moreover, door to balloon time is not the only metric being evaluated to most appropriately treat patients with ACS; recent feasibility data from the RAPID STEMI (A prospective randomized evaluation of a pharmacogenomic approach to antiplatelet therapy among patients with ST-elevation myocardial infarction) trial has demonstrated feasibility of point of care genotyping for the CYP2C19*2 allele potentially providing more individualized antithrombotic therapy.58
Developments in pre‐hospital patient transport in ST‐elevation myocardial infarction
2017, Revista Portuguesa de CardiologiaDoor-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary angioplasty
2021, European Heart Journal - Quality of Care and Clinical Outcomes3 = 1: cooperative provision of PCI treatment in a rural region
2020, Notfall und Rettungsmedizin
Statement of Conflict of Interest: see page 238.