D2B Time Research Articles

Healthcare-based on Cloud Electrocardiogram System: A Medical Center Experience in Middle Taiwan.

Electrocardiogram (ECG) as one of the best methods to measure irregular heartbeats is a dispensable method for doctor to diagnose Acute Myocardial Infarction (AMI) patients. Most medical centers in Taiwan implement the reduction of Door to Balloon (D2B) time, which is defined as the time interval starting when an Acute-Myocardial-Infarction patient arrives at the Emergency Department, and ending when a catheter guide wire crosses the culprit lesion as the acute-myocardial-infarction treatment on the patient in the cardiac catheterization room. Generally, when a patient with acute-chest pain is sent into a hospital (always to Emergency Department), the hospital will collect his/her ECG which needs to be evaluated by a cardiologist to ensure that the patient really has Acute Myocardial Infarction. Then the medical workers deliver the patient to the cardiac catheterization room to operate balloon angioplasty. In previous years, the cardiologist must utilize a PC to connect to the Intranet of the hospital and employ a special PACS (Picture Archiving and Communication System) image browser before he/she can check the patient's ECG. But this will prolong the D2B time since the doctor may stay outdoors and he/she needs some time to find a PC and network. Of course, if the PC has not installed the PACS image browser, the doctor has to download and install it. Consequently, the D2B time should be worsened, thus possibly impacting the patient's life. Therefore, in this paper, we introduce a Cloud-based Electrocardiogram System, with which cardiologists can directly utilize their smart phones to browse the patient's ECG so as to shorten the D2B time. This system has been online in a medical center in middle Taiwan for more than one year. The shortened D2B time is longer than 10min, i.e., receiving fine results.

Implementation of an ST-Segment Elevation Myocardial Infarction Bypass Protocol in the Northern United Arab Emirates.

Objective:The aim was to evaluate the translation of an ST-segment elevation myocardial infarction (STEMI) bypass protocol to the outcomes of patients with acute coronary syndrome in the Emirate of Ras al-Khaimah in the United Arab Emirates (UAE).Methods:A prospective cohort study was conducted, which included all patients who had a prehospital 12-lead electrocardiogram (ECG) performed by ambulance crews. Analysis of those who were identified as having STEMI and who subsequently underwent percutaneous coronary intervention (PCI) was performed.Results:A total of 152 patients had a 12-lead ECG performed during the pilot study period (February 24, 2016–August 31, 2016) with 118 included for analysis. Mean patient age was 52 years. There were 87 male (74%) and 31 female (26%) patients. Twenty-nine patients suffered a STEMI, and data were available for 11 who underwent PCI. There was no mortality, and no major adverse cardiac events were reported. The median door-to-balloon (D2B) time was 73 min (range 48–124), and 81% of patients had a D2B time < 90 min. Discharge data were available for six patients: All were discharged home with no impediments to rehabilitation.Conclusion:This pilot study has demonstrated agreement with the existing literature surrounding prehospital ECG and PCI activation in an unstudied STEMI population and in a novel clinical setting. It has demonstrated a D2B time of < 90 min in over 80% of STEMI patients, and a faster mean D2B time than self-presentations (mean 77 min vs. 113 min), with no associated mortality or major adverse cardiac events.

In hospital outcomes of primary percutaneous intervention in patients presenting with acute myocardial infarction in Saudi Arabia – A single center study

OBJECTIVE: To study the presentation, response to treatment, complication and prognosis of patients with acute ST-Elevation myocardial infarction (STEMI) who were treated with primary percutaneous coronary intervention (PPCI) at King Faisal Cardiac Center (KFCC) in the period from January 2015 till December 2016. METHODS: Data of 77 patients with STEMI who were treated with primary PCI as a mode of reperfusion who presented to KFCC were collected retrospectively from January 2015 till December 2016. The primary end point was in hospital mortality. RESULTS: 77 patients with STEMI received PPCI. These were predominantly male (86%, no=66). The mean age was 57.9 (SD ± 11.8). History of Diabetes was present in (64.7%, no=49), hypertension (49% no=38) dyslipidemia (51% no=39) and smoking (41.6%, no=32). Chest pain was the most common presenting symptoms (97%, no=75). Only 5 patients (6%) presented to emergency department within 1 hour from chest pain onset. While 7 (8%) of patients presented beyond 12 hours the majority of patients arrived within 6 hours 29 patients (38%) and 37 patients (48%) arrived after 6 hours but within 12 hours from pain onset. The median door to balloon time was 84 minutes (IQR: 63.5- 111.5 minutes). Door to balloon time of less than 90 minutes was achieved in (62%, no=46) while D2B time of more than 90 minutes but within 120 minutes was seen in (22 %,) while (16%) had D2B time of more than 120 minutes. The left anterior descending artery was the culprit in 37 patients (48%) Femoral artery access was used in 48 patients (62%).The success of delivering the stent was 97% (no =75). The Median length of hospital stay was 3 days (IQR: 2-4). The primary endpoint of inhospital death was 5.1%. CONCLUSION: Our findings suggest favorable outcomes of STEMI patients treated with PPCI, matching the international data. D2B time remains below acceptable standers. Regardless of logistic limitations Primary PCI should be the preferred method of reperfusion. Strategies towards increasing patient’s access and improving D2B time should be adopted.

Smartphone transmission of electrocardiography images to reduce time of cardiac catheterization laboratory activation

BackgroundThis retrospective study evaluated the use of a smartphone application to facilitate communication between the emergency physician (EP) and the interventional cardiologist in order to minimize the time to cardiac catheterization laboratory (CCL) activation and time to percutaneous coronary intervention (PCI). MethodsWe retrospectively collected pertinent time-points in the management of patients diagnosed with STEMI in the emergency department and their outcome. The primary outcome was the reduction in the time from ECG interpretation to CCL activation after the implementation of a smartphone application. A total of 84 patients were enrolled. Patients' electrocardiography (ECG) were described by traditional verbal communication via telephone (group 1, n = 40) and by additional smartphone transmission of ECG images to an interventional cardiologist (group 2, n = 44). Relevant time-points were recorded for analysis. ResultsThe time from ECG interpretation to CCL activation was reduced from 28.3 ± 4.1 in group 1 to 17.6 ± 2.3 min in group 2 (p = 0.03). Similarly, the time from ECG interpretation to balloon inflation time (D2B) decreased from 93.1 to 73.4 min (p = 0.025). Comparing group 2 with group 1, the door to balloon (D2B) time improved to 90.4 ± 9.8 from 119.3 ± 16.3 min (p = 0.23), the proportion of patients with a D2B time less than 90 min increased to 70.5% from 52.5% (p = 0.09), and the mortality rate decreased to 2.2% from 12.5% (p = 0.07). ConclusionThe additional use of a smartphone application to transmit ECG information to interventional cardiologists by EPs facilitated communication and reduced the decision time to CCL activation and percutaneous intervention.

Abstract 24024: Utilizing Telemedicine to Construct Population-Based STEMI Systems of care in Developing Countries

Background: Major disparities exist between developed and developing countries in the outcomes of patients presenting with Acute Myocardial Infarction (AMI). Telemedicine has emerged as a powerful, cost-efficient, and scalable tool. Whether telemedicine can improve AMI results remains unclear. Methods: We incorporated a hub and spoke strategy for Latin America Telemedicine Infarct Network (LATIN) to expand access to care in regions in Brazil, Colombia, and Mexico that lacked AMI care. Small clinics and primary care health centers in remote areas (spokes) were strategically connected to hubs that could perform 24/7 primary PCI. Experts at 3 central sites in Uberlandia, Sao Paulo, and Bogota, provided urgent EKG diagnosis and tele-consultation for the entire LATIN network by triggering ambulance dispatch and implementing standardized AMI protocols. Results: A total of 257 LATIN centers (Brazil 95, Colombia 113, Mexico 49) were networked using similar telemedicine protocols. In Colombia, LATIN coverage was established to cover 31% of the nation’s 48 million population. With this expanded geographic reach, 4.694 (1.2%) of the 401,095 screened patients were diagnosed as having STEMI. A total of 2,041 (43.5%) STEMI were urgently reperfused. Primary PCI was performed in the majority of patients - 1,578 (77.3%) that were referred for urgent perfusion. The major reasons for non-treatment included insurance denials, lack of ICU beds and chest pain &gt;12 hours. Time to Telemedicine Diagnosis (TTD) was 5.1 minutes, and tele-ECG accuracy was 98%. D2B time for the cohort was 53 minutes, but chest pain to treatment time was &gt;6 hours. Overall, in-hospital mortality was 5.8%. Conclusions: LATIN demonstrates the feasibility of creating a population based and telemedicine-guided AMI management strategy that can hugely expand access to reperfusion strategies. Telemedicine has important public health implications as a global approach to urgent AMI care in developing countries.

Effect of regional synergistic treatment system on the treatment time and short-term prognosis of ST-segment elevation myocardial infarction

To explore the effect of regional synergistic treatment system on the treatment time and short-term prognosis of patients with ST-segment elevation myocardial infarction (STEMI). A retrospective analysis of the clinical data of STEMI patients who admitted to emergency center of Suzhou Kowloon Hospital Affiliated to Shanghai Jiaotong University School of Medicine and underwent primary percutaneous coronary intervention (PPCI) from January 2013 to January 2017 were conducted. All patients were divided into two groups, group A was the patients who underwent the PPCI before the establishment of the acute chest pain area co-treatment system (from January 2013 to December 2014), and group B was the patients who received the treatment after the establishment of the area co-treatment system (from January 2015 to January 2017). The length of time from onset of symptoms to the balloon dilatation (S2B), the length of time from the first medical contact to the balloon dilatation (FMC2B), the length of time from entering the gate of hospital to the balloon dilatation (D2B), and the incidence of 90-day end point events (including heart failure, all-cause death, and other related adverse events) were collected. The relations of the establishment of the acute chest pain area co-treatment system and the incidence of 90-day end point events were analyzed by multivariable Logistic regression analysis. Among the 221 enrolled patients with STEMI, 83 patients were in group A and 138 patients were in group B respectively. Compared with group A, S2B time [minutes: 180 (140, 210) vs. 201 (154, 225)], FMC2B time [minutes: 89 (78, 100) vs. 94 (83, 107)] and D2B time [minutes: 66 (62, 70) vs. 85 (72, 99)] were significantly shortened in group B (all P < 0.05), the incidence of 90-day end point events were significantly decreased (heart failure: 20.3% vs. 32.5%, all-cause death: 1.4% vs. 7.2%, other related adverse events: 23.2% vs. 36.1%, all P < 0.05). It was shown by multivariable Logistic regression analysis that the establishment of the acute chest pain area co-treatment system could lower the incidence of 90-day end point events [heart failure: odds ratio (OR) = 1.904, 95% confidence interval (95%CI) = 0.968-1.004, P = 0.048; all-cause death: OR = 11.724, 95%CI = 0.955-1.048, P = 0.013; other related adverse events: OR = 1.925, 95%CI = 1.049-3.530, P = 0.034]. The construction of regional synergistic treatment system can shorten the emergency treatment time of STEMI patients and reduce the incidence of 90-day end point events including heart failure and death.

Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention.

ObjectiveTo evaluate causes and impact of delay in the door-to-balloon (D2B) time for patients undergoing primary percutaneous coronary intervention (PPCI).Subjects and methodsFrom January 2009 to December 2012, 1268 patients (86% male, mean age of 58 ± 12 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: Non-delay defined as D2B time ≤ 90 mins and delay group defined as D2B time > 90 mins. Data were collected retrospectively on baseline clinical characteristics, mode of presentation, angiographic findings, therapeutic modality and inhospital outcome.Results202 patients had delay in D2B time. There were more female patients in the delay group. They were older and tend to self-present to hospital. They were less likely to be smokers and have a higher prevalence of prior MI. The incidence of posterior MI was higher in the delay group. They also had a higher incidence of triple vessel disease.The 3 most common reasons for D2B delay was delay in the emergency department (39%), atypical clinical presentation (37.6%) and unstable medical condition requiring stabilisation/computed tomographic imaging (26.7%). The inhospital mortality was numerically higher in the delay group (7.4% versus 4.8%, p = 0.12).ConclusionsDelay in D2B occurred in 16% of our patients undergoing PPCI. Several key factors for delay were identified and warrant further intervention.

Impact of around-the-clock in-house cardiology fellow coverage on door-to-balloon time in an academic medical center.

ObjectivesTo assess if a change in our cardiology fellowship program impacted our ST elevation myocardial infarction (STEMI) program.BackgroundFellows covering the cardiac care unit were spending excessive hours in the hospital while on call, resulting in increased duty hours violations. A night float fellow system was started on July 1, 2012, allowing the cardiac care unit fellow to sign out to a night float fellow at 5:30 pm. The night float fellow remained in-house until the morning.MethodsWe performed a retrospective study assessing symptom onset to arrival, arterial access to first device, and door-to-balloon (D2B) times, in consecutive STEMI patients presenting to our emergency department before and after initiation of the night float fellow system.ResultsFrom 2009 to 2013, 208 STEMI patients presented to our emergency department and underwent primary percutaneous coronary intervention. There was no difference in symptom onset to arrival (150±102 minutes vs 154±122 minutes, p=0.758), arterial access to first device (12±8 minutes vs 11±7 minutes, p=0.230), or D2B times (50±32 minutes vs 52±34 minutes, p=0.681) during regular working hours. However, there was a significant decrease in D2B times seen during off-hours (72±33 minutes vs 49±15 minutes, p=0.007). There was no difference in in-hospital mortality (11% vs 8%, p=0.484) or need for intra-aortic balloon pump placement (7% vs 8%, p=0.793).ConclusionIn academic medical centers, in-house cardiology fellow coverage during off-hours may expedite care of STEMI patients.

Timely Reperfusion in Stroke and Myocardial Infarction Is Not Correlated: An Opportunity for Better Coordination of Acute Care.

Timely reperfusion is critical in acute ischemic stroke (AIS) and ST-segment-elevation myocardial infarction (STEMI). The degree to which hospital performance is correlated on emergent STEMI and AIS care is unknown. Primary objective of this study was to determine whether there was a positive correlation between hospital performance on door-to-balloon (D2B) time for STEMI and door-to-needle (DTN) time for AIS, with and without controlling for patient and hospital differences. Prospective study of all hospitals in both Get With The Guidelines-Stroke and Get With The Guidelines-Coronary Artery Disease from 2006 to 2009 and treating ≥10 patients. We compared hospital-level DTN time and D2B time using Spearman rank correlation coefficients and hierarchical linear regression modeling. There were 43 hospitals with 1976 AIS and 59 823 STEMI patients. Hospitals' DTN times for AIS did not correlate with D2B times for STEMI (ρ=-0.09; P=0.55). There was no correlation between hospitals' proportion of eligible patients treated within target time windows for AIS and STEMI (median DTN time <60 minutes: 21% [interquartile range, 11-30]; median D2B time <90 minutes: 68% [interquartile range, 62-79]; ρ=-0.14; P=0.36). The lack of correlation between hospitals' DTN and D2B times persisted after risk adjustment. We also correlated hospitals' DTN time and D2B time data from 2013 to 2014 using Get With The Guidelines (DTN time) and Hospital Compare (D2B time). From 2013 to 2014, hospitals' DTN time performance in Get With The Guidelines was not correlated with D2B time performance in Hospital Compare (n=546 hospitals). We found no correlation between hospitals' observed or risk-adjusted DTN and D2B times. Opportunities exist to improve hospitals' performance of time-critical care processes for AIS and STEMI in a coordinated approach.

Abstract 074: Door to Balloon Time in Patients With ST Elevation Myocardial Infarction With and Without Cardiopulmonary Arrest: is Exclusion From Public Reporting Justified?

Background: Since 2006 the Center for Medicare and Medicaid Services has allowed hospitals to exclude public reporting of door to balloon (D2B) time data for STEMI patients with cardiopulmonary arrest (CPA) within 90 minutes after hospital arrival, a high risk group with 30% in-hospital mortality. In July 2014, we implemented a high reliability STEMI process with rapid reperfusion goals for all STEMI patients treated with primary PCI at our center with no patient exclusions (figure). We studied D2B times for patients with and without in-hospital CPA before and after implementation of our high reliability STEMI process to clarify whether exclusion from public reporting on the basis of CPA is justified. Methods: We compared consecutive cases of STEMI treated with primary PCI at our center before (January 2013 to July 15 th , 2014) and after (July 16 th , 2014 to October 2016) implementation of a high reliability STEMI process, and we assessed D2B times in patients with and without in-hospital CPA prior to primary PCI. The primary endpoint was the % of patients treated within guideline D2B times ( &lt; 90 minutes for ED presenting patients or &lt; 120 minutes for inter-hospital transfer patients). Results: Over the study period 795 cases of STEMI were treated with primary PCI at our center. The control group constituted 37.4% (297/795) of patients who were treated prior to July 15 th , 2014, and the high reliability group constituted 62.6% (498/795) of patients treated after July 15 th , 2014. Patients presenting to our primary ED were 27.3% (217/795), inter-hospital transfer patients were 69.1% (549/795), and in-hospital STEMI patients were 3.6% (29/795). CPA within 90 minutes of hospital arrival occurred in 6.3% (50/795) of patients overall, and CPA was more prevalent in the control group vs the high reliability group (8.8% [26/297] vs 4.8% [24/498], P=0.027). In the control group patients with CPA were less likely to achieve goal D2B times compared to patients without CPA (30.8% [8/26] vs 60.5% [164/271], P=0.003), whereas in the high reliability group there was no difference in the rate of achievement of goal D2B times in patients with vs without CPA (75.0% [18/24] vs 81.6% [387/474], P=0.418). Conclusion: High reliability STEMI processes can improve delivery of care for the most vulnerable and highest risk patients.

Transradial versus Transfemoral Approach for Primary Percutaneous Coronary Intervention – Single Centre Experience over a Period of Two Years

Background: Primary percutaneous coronary intervention (PPCI) is preferred over thrombolysis due to its better outcome both in terms of morbidity and mortality. Transradial (TR) PPCI is favored over transfemoral (TF) approach due to several advantages including survival benefit. Only concern of TR PPCI is a possible delay in door-to-balloon (D2B) time which is an important parameter for a better outcome. This retrospective analysis compared various outcome variables including D2B time between TF versus TR groups in order to decide which approach provides better outcome over the other.Methods: This study was conducted at Ibrahim Cardiac Hospital &amp; Research Institute (ICHRI) on retrospective data collected over a period of 2 years between January 2013 to December 2014. Patients with ST-segment elevation myocardial infarction (STEMI) attending at Emergency Department of ICHRI within 12 hours of chest pain and were sent for PPCI were consecutively included in the study based on predefined enrollment criteria. Demographic, angiographic &amp; angioplasty variables, D2B time, duration of hospital stay and mortality were compared between TF versus TR groups.Results: Of the 92 patients included in the study, 47(51.1%) patients underwent PPCI through TF access whereas 45(48.9%) patients through TR access. There was an increasing trend of performing PPCI via TR access in 2014 compared to 2013 (64.4% vs. 35.6%). There was no significant difference between the study groups in terms of age and sex. Baseline angiographic &amp; angioplasty variables were almost similar between the groups. The mean D2B time was significantly shorter in TR group than that in TF group (79.0 ± 34.6 vs. 90.3 ± 37.7 min, p=0.021). One patient in each group died from ventilator associated pneumonia after PPCI.Conclusion: Our single center retrospective analysis showed a statistically significant decrease in the door to balloon time with TR PCI, which makes it an attractive option for PPCI in STEMI.University Heart Journal Vol. 11, No. 2, July 2015; 56-62

Influencial factors for in-hospital patients with ST segment elevation myocardial infarction after emergency percutaneous coronary intervention

To analyze the clinical outcomes of emergency percutaneous intervention in acute myocardial infarction (AMI) during hospital, and to find the relevant risk factors for the prognosis and cardiac events. Methods: We retrospective analyzed the patient with acute ST segment elevation myocardial infarction, who was successfully performed emergency percutaneous coronary intervention (PCI) in the Cardiac Cath Lab of the Second Xiangya Hospital from January 2010 to December 2014. According to situation for cardiovascular events, patients were divided into 2 groups. The clinical factors were compared between the 2 groups. Results: The incidence of adverse event was 22% (67/304). By using t test and χ2 analysis, we found that Cr, NT-proBNP, HCT, WBC, age>75, Killip grade≥2, TIMI flow after PCI≤2, arrhythmia, multi-vessel lesion, ST-segment resolution≥50%, long D2B time are statistically different between the 2 groups. Logistic analysis revealed that HCT, NT-proBNP, Killip grade≥2, TIMI flow after PCI≤2, ST-segment resolution≥50%, long D2B time were important predictors for cardiac events in-hospital. Conclusion: HCT, NT-proBNP, Killip grade≥2, TIMI flow after PCI≤2, ST-segment resolution≥50%, long D2B time are important predictors for cardiac events in-hospital. The prognosis for AMI patient after emergency PCI could be improved and the incidence of cardiac event in hospital could be reduced if the high risk factors can be properly handled.

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction.

ObjectiveTo evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI).MethodsFrom January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age ≥ 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course.ResultsThe elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher.ConclusionsOur registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.

The effect of door-to-balloon delay in primary percutaneous coronary intervention on clinical outcomes of STEMI: a systematic review and meta-analysis protocol

BackgroundAcute myocardial infarction (AMI) is a medical emergency in which sudden occlusion of coronary artery(ies) results in ischemia and necrosis of the cardiac tissues. Reperfusion therapies that aim at reopening the occluded artery remain the mainstay of treatment for AMI. Primary percutaneous coronary intervention (PCI), which enables the restoration of blood flow by reopening the occluded artery(ies) via a catheter with an inflatable balloon, is currently the preferred treatment for AMI with ST segment elevation (STEMI). The door-to-balloon (D2B) delay refers to the time interval counting from the arrival of a patient with STEMI at a hospital to the time of the balloon inflation (or stent deployment) that reopens the occluded artery(ies). Reducing this delay in primary PCI is thought to be an important strategy toward achieving better patient outcomes. Unfortunately, significant reduction of D2B delay in the USA over the last decade has not been shown to be associated with improved STEMI mortality. It has been suggested that the lack of impact could be due to the expanding use of primary PCI in STEMI as well as the survival cohort effect, leading to a shift toward a higher risk population receiving the procedure. Others have suggested that reduction in D2B delay may not be as impactful as expected, given that it only represents a small fraction of the total ischemic time. Although most existing evidence have pointed to the presence of a beneficial effect of shorter D2B delay, some inconsistencies however exist. This study aims to synthesize available evidence in order to answer the following questions: (1) what is the overall effect of D2B delay on clinical outcomes in patients with STEMI treated with primary PCI? (2) What factors explain the differences of the effect estimates among the studies? (3) What are the important strength and limitation of the existing body of evidence?MethodWe will search PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, WHO International Clinical Trials Registry, CINAHL Database, and the Cochrane Library using a predefined search strategy. Other sources of literature will include proceedings from the European Society of Cardiology, the American College of Cardiology, the American Heart Association, the EUROPCR, and the ProQuest Dissertations and Theses Database. We will include data from observational studies (case-control and cohort study design) and randomized control trials (that have investigated the relationship of D2B time and clinical outcome(s) in an adult (older than 18) STEMI population). Mortality (cardiac related and all-cause) and incidence heart failure (HF) have been prioritized as the primary outcomes. All eligible studies will be assessed for risk of bias using the Risk Of Bias in Non-randomized Studies - of Interventions tool. The Grading of Recommendations, Assessment, and Evaluation (GRADE) framework will be used to report the quality of evidence and strength of recommendations. We will proceed to analyze the data quantitatively if the pre-specified conditions are satisfied.DiscussionRecent discussion on the negative findings of improved D2B delay over time being unrelated to better STEMI outcomes at the population level has reminded us of an important knowledge gap we have on this domain. This systematic review will serve to address some of these key questions not previously examined. Answers to these questions could clarify the controversies and offer empirical support for or against the suggested hypotheses.Systematic review registrationPROSPERO CRD42015026069Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0304-7) contains supplementary material, which is available to authorized users.

Age-dependent impact of new ESC-Guideline recommended door-to-balloon times on mid-term survival in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

BackgroundTo investigate the age-dependent impact of the superfast door-to-balloon (D2B) times of ≤60min as recommended by the new ESC Guideline for patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) on mid-term survival rates based on a single center registry dataset. Patients and methodsThis study enrolled consecutive STEMI patients who underwent PPCI from Jan 1, 2009 through Sep 30, 2013. We compared demographics, clinical characteristics and the D2B-survival relationships between patients aged ≥65 and <65. ResultsThe younger group comprised 242 patients (68%) aged <65 and the elder group consisted of 115 patients (32%) aged ≥65. In patients aged <65, the mortality rate decreased linearly with D2B time shortening (>90min vs. 61–90min vs. ≤60min=14.9% vs. 13.3% vs. 1.2%, P=0.001). Contrarily, shortening of D2B time was not associated with reduced mortality rate in patients aged ≥65 (>90min vs. 61–90min vs. ≤60min=23.5% vs. 19% vs. 18.9%, P=0.99). In younger patients but not the elderly, a D2B time of <60min has sufficient power to predict mortality with a sensitivity of 0.83, specificity of 0.74, and Youden index of 0.57. ConclusionsOur results show that the new ESC Guideline recommendation of D2B time ≤60min is associated with better survival rates in younger STEMI patients undergoing PPCI. Our findings stress the importance of guideline adherence to minimize reperfusion delay to improve survival in these patients.

Reply to the Letter to the Editor for the Article Entitled "Effects of Door-to-Balloon Times on Outcomes in Taiwanese Patients Receiving Primary Percutaneous Coronary Intervention: A Report of Taiwan Acute Coronary Syndrome Full Spectrum Registry" Published in the Journal of Acta Cardiologica Sinica in 2015 (2015;31:215-225).

The article entitled “Effects of Door-to-Balloon Times on Outcomes in Taiwanese Patients Receiving Primary Percutaneous Coronary Intervention: A Report of Taiwan Acute Coronary Syndrome Full Spectrum Registry” was published in the Journal of Acta Cardiologica Sinica in early 2015.1 This is the first large-scale (> 1000 patients) domestic report which investigated whether or not increasingly lower door-to-balloon (DTB) time correspondingly improves clinical outcomes. One expert(s) wrote a Letter to the Editor and questioned whether the significant relationship between 1-year major adverse cardiac events and DTB time < 45 minutes was statistically adjusted by use of drug-eluting stent (DES). The letter also referenced our previous study to reinforce that the DES-treated group had fewer cardiovascular events as compared to the BMS (bare-metal stent)-treated group.2 In fact, we selected all variables with a statistical trend or significance (p < 0.15), as listed in Table 1 and 2, including stent type, for univariate analysis. The variable of stent type did not reach a statistical significance using univariate analysis. Importantly, it is necessary to highlight here that such statistical processing remains insufficient to exclude the potential effects of the different stent types on cardiovascular outcome. In addition, the expert(s) shared data about a 5-year cohort study involving 951 patients with ST-segment elevation myocardial infarction (STEMI) showing that DTB time was strongly associated with annual mortality (1.001-1.004; p < 0.001). They suggest that DTB time is an important prognostic factor for annual mortality. Of course we will unquestionably review the entire available domestic data. On the other hand, the article concludes that DTB time is not a good determinant for 1-year cardiovascular outcome. It is consistent with the fact that current evidence remains conflicting about the association between mortality rate and DTB time.3,4 We believe that the impact of DTB time on clinical outcome, especially on long-term outcome, is very complicated due to numerous confounders. Irrespective of the impact of DTB time on long-term outcome, we have emphasized in our study that a D2B time must be aggressively shortened to minimize myocardial damage based upon the belief that “time is muscle” in STEMI patients. In other words, coronary interventionalists should expedite the process of revascularizing the infarct-related coronary artery without delay to most efficaciously manage patients with STEMI.

27. The impact of introduction of code-stemi program on clinical outcomes of acute st-elevation myocardial infarction (stemi) patients undergoing primary pci: Single center study in Saudi Arabia

This study was conducted to evaluate the effect of direct Emergency Department activation of the Catheterization Lab on door to balloon (D2B) time and outcomes of acute ST-elevation myocardial infarction (STEMI) patients in King Khalid University Hospital (KKUH). Establishing dedicated comprehensive STEMI programs aiming at reducing door to balloon time will impact favourably the outcomes of patients presenting with acute STEMI. This was a retrospective cohort study that involved 100 patients in KKUH who presented with acute STEMI and underwent primary percutaneous intervention (PPCI), between June 2010 and January 2015. The cohort was divided into two groups, the first group consisted of 50 patients who were treated before establishing the Code-STEMI protocol, whereas the second group were 50 patients who were treated according to the protocol, which was implemented in June 2013. Code-STEMI program is a comprehensive program that includes direct activation of the cath lab team using a single call system, data monitoring and feedback, and standardized order forms. The mean age in both groups was 54 ± 12 years and 86% (43) and 94% (47) of the patients in the two groups were males, respectively. 90% (90) of patients in both groups had one or more comorbidities.Code-STEMI group had a significantly lower D2BT with 70% of patients treated within the recommended 90 minutes (median = 76.5 min, IQR: 63–90 min) compared to only 26% of pre code-STEMI patients (median = 107 min, IQR: 74–149 min) In-hospital complications were lower in the Code-STEMI group; however, the only statistically significant reduction was in non-fatal re-infarction, (8% vs. 0%, p = 0.043). In addition, the number of patients with more than one in-hospital complications was also reduced by 20%.Implementation of direct ER-Catheterization lab activation protocol was associated with a significant reduction in D2B time, and an overall improvement of in-hospital outcomes.

27 Impact of Culprit Versus Non-Culprit Angiography Strategy on Primary PCI Door to Balloon Times

Background Guidelines for ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (PPCI) within 90 min of arrival in a PCI-capable hospital. Some PCI operators perform diagnostic angiography of the non-culprit artery prior to intervention (‘non-culprit’ strategy) while others proceed directly to the presumed culprit vessel (‘culprit’ strategy) reserving imaging of the non-culprit vessel until after the PCI. We evaluated the ‘time cost’ of each approach and their impact upon door to balloon times (D2B). Methods All consecutive patients presenting with STEMI to a regional heart attack centre between April 2014 and March 2015 (n = 630) were included. The time from the first angiogram acquisition (culprit or non-culprit vessel) to device use (thrombectomy catheter, balloon or stent) was recorded for each strategy. Overall D2B times were analysed. Results A culprit strategy was followed in 69/630 and a non-culprit approach in 561/630. The mean time from first image to device use was 15 mins 41s for non-culprit strategy and 8 mins 9s for culprit strategy. The non-culprit strategy therefore incurred a delay of 7 mins 32s (p 90mins (p = 0.02). Conclusion A ‘culprit’ PPCI strategy results in significantly shorter D2B times, facilitating institutional attainment of national guideline targets, which may translate into improved patient outcomes.

Association of Guideline-Based Admission Treatments and Life Expectancy After Myocardial Infarction in Elderly Medicare Beneficiaries

BackgroundGuideline-based admission therapies for acute myocardial infarction (AMI) significantly improve 30-day survival, but little is known about their association with long-term outcomes. ObjectivesThis study evaluated the association of 5 AMI admission therapies (aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon [D2B] time ≤90 min, and time to fibrinolysis ≤30 min) with life expectancy and years of life saved after AMI. MethodsWe analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI, with 17 years of follow-up. Life expectancy and years of life saved after AMI were calculated using Cox proportional hazards regression with extrapolation using exponential models. ResultsSurvival for recipients and non-recipients of the 5 guideline-based therapies diverged early after admission and continued to diverge during 17-year follow-up. Receipt of aspirin, beta-blockers, and acute reperfusion therapy on admission was associated with longer life expectancy of 0.78 (standard error [SE]: 0.05), 0.55 (SE: 0.06), and 1.03 (SE: 0.12) years, respectively. Patients receiving primary percutaneous coronary intervention (PCI) within 90 min lived 1.08 (SE: 0.49) years longer than patients with D2B times >90 min, and door-to-needle (D2N) times ≤30 min were associated with 0.55 (SE: 0.12) more years of life. A dose–response relationship was observed between longer D2B and D2N times and shorter life expectancy after AMI. ConclusionsGuideline-based therapy for AMI admission is associated with both early and late survival benefits, and results in meaningful gains in life expectancy and large numbers of years of life saved in elderly patients.

Impact of a single universal guiding catheter on door-to-balloon time in primary transradial coronary intervention for ST segment elevation myocardial infarction

The purpose of this study is to determine reduction of door-to-balloon (D2B) time using a single universal guiding catheter (Ikari-Left catheter) in transradial approach. In this procedure, we can skip a total of five steps compared with a conventional procedure (two catheter insertions, two catheter removals, and one catheter engagement). Reducing total ischemic time is important to achieving a better outcome in primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). We retrospectively compared 30 consecutive STEMI patients who underwent transradial primary PCI with a single guiding catheter (IL group) with 30 consecutive patients with conventional transradial primary PCI. Patients with cardiogenic shock, heart failure, or need for intra-aortic balloon pumping support before primary PCI were excluded. Baseline characteristics were not different between the two groups. The D2B time was significantly shorter in the IL group (55 ± 16 vs. 63 ± 17 min, respectively; p = 0.01). Puncture-to-balloon time was also significantly shorter in the IL group (15 ± 11 min vs. 25 ± 11 min, respectively; p = 0.001). The total number of diagnostic and guiding catheters was significantly less in IL group (1 (IQR 1-1) vs. 3 (IQR 3-3), respectively; p < 0.0001). Primary PCI with a single universal guiding catheter reduced D2B time by skipping several procedural steps, and reduced the total number of catheters needed. This technique could reduce patient mortality as well as total medical cost.