Primary angioplasty in Portugal: door-to-balloon time is not a good performance index

Abstract

Despite primary angioplasty being the recommended treatment for patients with acute myocardial infarction with ST-elevation, recent studies have shown a great heterogeneity in the access to this form of treatment in Europe. The project "Stent for Life", an initiative of the European Society of Cardiology which Portugal joined in February 2011, aims to improve this situation. The objective of this study was to re-evaluate the basic Portuguese performance indicators for primary angioplasty. A national survey called "Moment Zero" was implemented for a one-month period for this purpose. Nineteen Portuguese centres of interventional cardiology, where primary angioplasty is carried out, were invited to participate in this study. From 9th May to 8th June 2011, 14 centres participated in this study and 185 patients were included with a mean age of 62±14 years, of which 76.8% were male. 17.5% of the patients presented with a medical history of diabetes mellitus, 8.4% had previous percutaneous coronary intervention, 7.6% myocardial infarction and 1.1% coronary artery bypass surgery. Only 29% of the patients used the single national number for medical emergencies (112) to call for support. The median patient delay was 120 (73-240) minutes. The median pre-hospital transportation system delay was 104 (73-240) minutes. The median door-to-balloon delay (D2B) was 64 (30-110) minutes and was not significantly different between patients who contacted the National Institute for Medical Emergency (INEM) and patients who did not contact this service: 69 (30-109) minutes versus 60 (30-111) minutes. In 56% of the cases, patients entered a local hospital before transferring to a hospital with primary angioplasty facilities. The time between the admission to the local hospital and admission to a hospital with an interventional cardiology unit was 109 (73-173) minutes. The main barriers to a better performance of the primary angioplasty programme in Portugal, as revealed by "Moment Zero", are the low number of patients who contacted the INEM and the high number of patients who attended centres without interventional cardiology units, resulting in long delays spent in secondary transportation to the institutions with such services. The D2B delay, although close to the 90 minutes recommended by the guidelines, is not a good indicator of the overall performance of primary angioplasty in Portugal.