Door-to-balloon Research Articles

BackgroundThe impact of atypical symptom presentation in ST-segment elevation myocardial infarction (STEMI) on treatment timeliness and long-term outcomes remains insufficiently characterized. This study aimed to examine the association between symptom presentation and delays in door-to-balloon (DTB) time components and short- and long-term mortality, and to identify triage characteristics independently associated with atypical STEMI presentation.MethodsWe conducted a retrospective cohort study of STEMI patients undergoing primary percutaneous coronary intervention at a tertiary hospital in Taiwan between 2013 and 2022. Symptom presentation was classified as typical or atypical based on emergency department triage records. Primary outcomes included delays in DTB components and all-cause mortality at 30 days, 1 year, and 3 years. The secondary outcome was identification of triage characteristics associated with atypical presentation. Multivariable Cox and logistic regression models were used.ResultsOf 807 patients, 13.5% presented with atypical symptoms. Atypical presentation was independently associated with higher 30-day (aHR: 2.20, 95% CI: 1.15–4.21), 1-year (aHR: 1.91, 95% CI: 1.09–3.37), and 3-year (aHR: 1.73, 95% CI: 1.04–2.87) mortality. It was also linked to delays in door-to-ECG (aOR: 11.52, 95% CI: 6.04–22.06), activation-to-Cath lab-arrival (aOR: 1.71, 95% CI: 1.04–2.80), and Cath lab-arrival-to-balloon time (aOR: 1.95, 95% CI: 1.24–3.06). Older age, female sex, diabetes, cerebrovascular disease, tachycardia, and hypotension were independently associated with atypical presentation.ConclusionsAtypical STEMI presentation is associated with treatment delays and increased short- and long-term mortality. Early identification of high-risk patients may improve timely care and clinical outcomes.Clinical trial numberNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12873-025-01368-9.

Challenges encountered by healthcare workers in managing door-to-balloon time of myocardial infarction: A survey.

BackgroundThe Saudi Acute Myocardial Infarction Registry (STARS) program aims to evaluate the clinical characteristics, management, and outcomes of a representative sample of patients with acute myocardial infarction (AMI) in Saudi Arabia. This second phase evaluates temporal changes in patient care, demographics, and the management benchmarks for AMI.Methods and findingsWe created a 5-year recurring, multi-center prospective registry that utilizes a snapshot design in 50 hospitals from various healthcare sectors in Saudi Arabia. The study’s recruitment phase spanned from September 3, 2021, to January 6, 2023. During these 16 months, 2,690 patients presenting with acute myocardial infarction (AMI) with or without ST-segment elevation (STEMI or NSTEMI, respectively) were enrolled. The mean age (± SD) of the overall population was 57 (±12.4) years, 70% were Saudi citizens, 82% were men, and (48.8%) of the total patients had STEMI. Fifty-eight percent of patients had diabetes mellitus and 58% had hypertension. Of the total population with STEMI, primary percutaneous coronary intervention (PCI) was performed in 619 patients (47.1%), thrombolytics were given to 584 patients (44.5%), and 110 patients had no reperfusion (8.4%). Among patients who presented within 24 h of symptom onset, the door-to-balloon (DTB) time was 63 min (IQR: 43), with 75.6% achieving DTB < 90 min, whereas the door-to-needle (DTN) was 25 min (IQR: 34), with 57% achieving DTN < 60 min. Thirty-nine percent of patients failed lytic reperfusion and 96% of these required rescue PCI. In 52% of instances, the failure to receive reperfusion therapy was attributed to patients’ late presentation. At presentation, only 8.5% of cases were transferred by the Emergency Medical Services. Approximately one-fourth of patients with NSTEMI did not undergo a coronary angiogram. All-cause mortality was 2.4% with no significant difference between sexes or nationalities.ConclusionThis nationwide AMI registry revealed younger age at presentation with a high prevalence of risk factors for coronary artery disease. While primary PCI key performance indicators have improved from the previous phase, further progress is needed in EMS utilization and acute revascularization for STEMI and NSTEMI.

Introduction: Cardiovascular disease remains the leading cause of death globally, with ST-elevation myocardial infarction (STEMI) posing the highest mortality among acute coronary syndromes (ACS). Early intervention, such as percutaneous coronary intervention (PCI), improves outcomes. Objective: To describe the clinical and demographic profile of STEMI patients in Indonesia and identify risk factors associated with disease severity.Methods: A retrospective descriptive study was conducted on STEMI patients who underwent PCI at a Heart Center Hospital from January to December 2024. Data from electronic medical records were analyzed, including only confirmed STEMI cases with complete documentation.Result: 87 patients were included, most male (92%) and aged over 50 (66.7%). Hypertension (49.4%), smoking (46%), and diabetes mellitus (27.6%) were common comorbidities. Leukocytosis occurred in 86.2%, with universally elevated troponin levels. Despite frequent cardiomegaly on chest X-rays, 46% had preserved ejection fraction on echocardiography. Inferior (34.5%) and anterior (19.5%, 17.2%) infarctions were the most common ECG findings. The left anterior descending (LAD) artery was affected in 85.1%, with three-vessel disease present in 49.4%. Mean door-to-balloon (DTB) time was 86.25 minutes. In Intra-PCI Complications, dissection in 2.3%.Conclusion: STEMI in Indonesia predominantly affects older males with modifiable cardiovascular risk factors. These factors are closely linked to severe coronary involvement, particularly multi-vessel disease.

To analyse patient profiles, transportation patterns and time delays in ischaemic time and door-to-balloon (DTB) time and evaluate the effect of these delays on in-hospital mortality among patients undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction (STEMI) at a tertiary care hospital in Colombo. Retrospective observational study. Tertiary care hospital specialising in STEMI treatment, located in Sri Lanka. The study included adults aged 16-87 years admitted for P-PCI between January 2018 and September 2023, presenting with STEMI and undergoing emergency P-PCI. Patients with incomplete records or unrealistic values on ischaemic time or DTB time were excluded. Outcome measures include ischaemic time, DTB time and in-hospital mortality. The associations of demographic factors, transfer methods and DTB time with survival rates were analysed. A total of 1758 patients underwent P-PCI (mean age, 53.0±11.64), with 85.2% being male. The male risk group was 46-60 years (OR, 1.22), whereas the female risk group was predominantly older than 60 years (OR, 1.87). The median ischaemic time was 4 hours and 36 min, and the median DTB time was 110 min. The in-hospital mortality rate was 3.8% (63/1,664). Prolonged DTB times exceeding 120 min were significantly associated with increased mortality (p=0.046), although alternative thresholds (45, 60 or 90 min) were not significant (p>0.05). Binary logistic regression with multiple variables identified female sex (OR, 2.52; 95% CI, 1.168 to 5.435, p=0.018), increasing age (OR 1.05; 95% CI, 1.016 to 1.085, p=0.004) and DTB times (OR, 1.001; 95% CI, 1.000 to 1.002, p=0.027) as independent predictors of mortality. Despite improvements in DTB times, this study indicates that prolonged delays exceeding 120 min remain associated with increased mortality. Older age and female sex were identified as independent predictors of higher mortality. These findings underscore the need for efficient patient transfer methods and prompt decision-making at the primary healthcare level to minimise delays and disparities in P-PCI outcomes.

BackgroundHeart failure with preserved ejection fraction (HFpEF) poses a significant global health challenge, disproportionately affecting women. Diabetic women with HFpEF represent a high-risk subgroup, particularly after experiencing ST-segment elevation myocardial infarction (STEMI), exhibiting increased mortality compared to men. While prolonged door-to-balloon (DTB) times, reflecting delayed reperfusion, are a critical factor in STEMI outcomes, they alone do not fully capture the observed outcome variability in diabetic women. Using an integrated clinical and pre-clinical approach this study aimed to investigate the relative contributions of metabolic dysfunction and coronary artery disease (CAD) in type 2 diabetes (T2D) to STEMI outcomes in women, beyond the impact of DTB time.MethodsA retrospective case–control study analysed female STEMI patients undergoing primary percutaneous coronary intervention (pPCI, n = 40 T2D, n = 40 non-diabetic controls), comparing clinical characteristics, treatment strategies, and early outcomes. A preclinical model (female db/db mice) assessed cardiac function via echocardiography, Langendorff perfusions, and ischemia–reperfusion protocols. Metabolome of heart, liver, and skeletal muscle was assessed by 1H NMR spectroscopy.ResultsOur study reveals significantly higher mortality, impaired left ventricular function post-pPCI, and increased implantable cardioverter-defibrillator (ICD) implantation rates in diabetic STEMI patients, irrespective of DTB time, when compared to non-diabetic controls. Elevated inflammatory markers, acute hyperglycaemia and evidence of cardio-hepatic damage were identified in T2D patients. db/db mice exhibited analogous T2D-associated pathophysiology, including increased ischemia–reperfusion injury exacerbated by metabolic disturbances in the myocardium, liver, and skeletal muscle versus non-diabetic controls.ConclusionsIn diabetic women, multiple factors beyond reperfusion delays exacerbate acute myocardial injury. This necessitates the development of sex-specific strategies to manage the cardiovascular complications of diabetic HFpEF. The db/db mouse model provides a relevant preclinical tool for future research as it mimics human T2D-associated HFpEF and STEMI outcome.

Abstract Background prompt reperfusion therapy is critical for patients with ST-segment elevation myocardial infarction (STEMI) to improve outcomes. Variability in regional healthcare delivery may influence treatment times and patient outcomes. Purpose to evaluate the differences in management and outcomes of STEMI patients across Northern, Central, and Southern Italy, focusing on time-dependent reperfusion and in-hospital logistics. Methods a prospective observational study conducted from September 1 to 25, 2023, including 554 STEMI patients treated at high-volume hub centers operating 24/7. Data were collected through structured surveys completed by Cath Lab directors across different Italian regions. Results primary outcomes included door-to-balloon (DTB) time, time from symptom onset to balloon inflation, and regional disparities in pre- and post-PCI management. Secondary outcomes included in-hospital mortality, discharge destinations, and medication regimens. The median DTB time was consistent across regions (30 minutes; IQR: 20-50 minutes). Significant regional disparities were noted in the time from symptom onset to balloon inflation, with the Southern and Islands region experiencing the longest median time (180 minutes) compared to the Central (170 minutes) and Northern (154 minutes) regions (p&amp;lt;0.01). The study revealed a significant reduction in DTB time associated with ECG teletransmission from ambulances (mean reduction of 25 minutes, p=0.03). In-hospital mortality rates were similar across regions (p=0.828). Conclusions this study highlights significant regional disparities in the management and treatment timelines of STEMI patients in Italy. Despite these differences, in-hospital care was consistently timely across regions, suggesting that pre-hospital logistics critically influence overall treatment times. Enhanced pre-hospital ECG teletransmission could further optimize reperfusion times, potentially improving patient outcomes.Time metrics for STEMI by region

Prompt reperfusion is critical for patients with ST-segment elevation myocardial infarction (STEMI) to improve outcomes. Yet, variability in regional healthcare delivery may influence treatment times and patient outcomes. We thus aimed at evaluating differences in management and outcomes of STEMI patients across Northern, Central, and Southern Italy, focusing on time-dependent reperfusion and in-hospital logistics. A prospective observational study conducted from September 1st to 25th, 2023, including 554 STEMI patients treated at high-volume hub centers operating 24/7. Data were collected through structured surveys completed by catheterization laboratory directors across different Italian regions. Primary outcomes included door-to-balloon (DTB) time, time from symptom onset to balloon inflation, and regional disparities in pre- and post-PCI management. Secondary outcomes included in-hospital mortality, discharge destinations, and medication regimens. The median DTB time was consistent across regions (30 minutes; IQR: 20-50 minutes). Significant regional disparities were however noted in time from symptom onset to balloon inflation, with Southern and Island regions experiencing longer median times (180 minutes) compared to Central (170 minutes) and Northern (154 minutes) regions (P<0.01). We also found a significant reduction in DTB time associated with ECG teletransmission from ambulances (mean reduction of 25 minutes, P=0.03). In-hospital mortality rates were similar across regions (P=0.83). This comprehensive nationwide analysis highlights significant regional disparities in the management and treatment timelines of STEMI patients in Italy. Despite these differences, in-hospital care was consistently timely across regions, suggesting that pre-hospital logistics critically influence overall treatment times. Enhanced pre-hospital ECG teletransmission could further optimize reperfusion times, potentially improving patient outcomes.

Abstract Introduction Coronary artery disease causes 4000 deaths per year in Portugal, but compliance with recommendations of the European Society of Cardiology for timely assessment and treatment may reduce morbidity and mortality. Delays can be identified and reduced. Objective To assess the association between the of presence of electrocardiography technicians in a hospital emergency room and compliance with target times recommended by European Society of Cardiology for care of patients with acute myocardial infarction. Methods Clinical records of patients admitted to an emergency room with acute myocardial infarction with ST-segment elevation or presumed new complete left bundle branch block between 2015 and 2019 were analyzed. Sociodemographic variables, triage status, door-to- electrocardiogram time, and door-to-balloon time data were assessed. The association between presence or absence of an ECG technician and mean time to ECG and catheterization was tested using the Student T-test. Results The study sample included 79 patients, with a mean age of 60.4 years ± 11.04. With electrocardiography technicians present, the mean door-to-electrocardiogram time was 6 minutes (1.0 to 40.5 minute 95% CI). In their absence, the mean time was 39 minutes (16 to 113 minutes 95% CI, p&amp;lt;.05). The mean door to-balloon time was 89 (79 to 113 minutes 95% CI) in the presence of a technician, and 148 minutes (110 and 273 minutes 95% CI) in the absence of technician (p&amp;lt;.05). In patients with typical symptoms, the observed door-electrocardiogram time was within the limits of guidelines of European Society of Cardiology in the presence of a technician, with a mean of 5.1 minutes. The mean door-to balloon time was 88.6 minutes. In the absence of a technician, the mean times were higher and outside current guidelines. Infarcts with atypical symptoms resulted in less accurate triage and longer times to electrocardiogram and diagnosis. Care was faster in the presence of an electrocardiography technician. Conclusions The presence of electrocardiography technicians significantly reduced door-to-electrocardiogram and door-to-balloon times in patients with myocardial infarction. Reinforcing hospital emergency departments with these professionals could improve the care provided to patients with acute myocardial infarction.

Background: Early identification and diagnosis are pivotal in the management of patients with acute myocardial infarction (AMI). The American Heart Association / American College of Cardiology (AHA/ACC) guidelines recommend obtaining an electrocardiogram (ECG) for patients who present to the emergency department (ED) with ischemic symptoms within 10 minutes of arrival. This is an important step in ensuring early administration of reperfusion therapy for those with an ST-elevation myocardial infarction (STEMI). A goal of ≤90 min or ≤ 120 min when transfer is involved is recommended for door-to-balloon (DTB) procedure time to reduce the risk of poor outcomes. However, past research has shown that sex disparities exist in ED triage and timely treatment of patients experiencing an AMI. The aim of this study was to assess sex differences in timely identification and treatment of patients presenting to the ED with AMI. Methods: We performed a retrospective cross-sectional analysis of 874 STEMI (234 females and 640 males) and 1,650 Non-STEMI (NSTEMI; 556 females, 1095 males) patients that presented to two urban EDs between January 1, 2022, and March 31, 2024. Sex differences in time to ECG (STEMI and NSTEMI) and DTB (STEMI only) were compared continuously, as well as categorically based on AHA/ACC recommendations (ECG delay: &gt;10 min, DTB delay: &gt;90 min or &gt;120 min with transfer). Continuous variables were compared using a multi-factor analysis of variance and categorical variables were tested using chi-square test of association. Results: Median time to ECG was 4.0 min longer for female compared to male STEMI patients, and 2.5 min longer for female vs male NSTEMI patients (ECG delay: 20.3% of female vs. 11.6% of male STEMI patients and 29.3% female vs. 20.3% of male NSTEMI patients). EMS activation time to ECG was also longer in females (+7.4 min for female STEMI patients and +2.9 min for female NSTEMI patients, compared to male counterparts). Similarly, DTB was 28.0 min longer when no transfer was involved and 15.2 min longer with transfer in female compared to male STEMI patients (DTB delay: 40.6% female vs. 37.0% male STEMI patients). Conclusion: In AMI patients presenting to the ED, female sex was associated with a significantly longer time to ECG. Female STEMI patients also had longer DTB times, which is associated with poorer outcomes. Initiatives are needed to understand these sex disparities and achieve the AHA/ACC guidelines for both time to ECG and DTB.

IntroductionThe most effective therapy for ST-segment elevation myocardial infarction (STEMI) is immediate primary percutaneous coronary intervention (pPCI).AimWe planned this study to evaluate the effect of emergency department delay time (EDDT) on in-hospital and 1-year all-cause mortality in STEMI patients who underwent pPCI.Material and methodsBetween October 2016 and May 2021, we examined 890 consecutive STEMI patients who had pPCI at our institution within 12 h of the onset of symptoms. The clinical endpoint of this study was in-hospital and 1-year all-cause mortality.ResultsThe cohort mostly comprised men (690 [77.5]), and their mean age was 60.7 ±13.5 years. The median EDDT was 23 (15–35) min, sheath-to-balloon (STB) time was 10 (7–13) min, and door-to-balloon (DTB) time was 34 (25–48) min. In multivariable logistic regression analysis EDDT (OR = 0.994; CI = 0.972–1.017; p = 0.611) was not a predictor for in-hospital mortality. In the multivariable Cox regression analysis, EDDT (HR = 1.011, CI = 1.002–1.021, p = 0.022), age (HR = 1.044, CI = 1.019–1.068, p < 0.001), left ventricle ejection fraction (HR = 0.957, CI = 0.931–0.988, p = 0.003), and glomerular filtration rate (HR = 0.982, CI = 0.966–0.997, p = 0.016) were the independent predictors of 1-year all-cause death across all causes.ConclusionsWe found that EDDT was an independent predictor among all causes for 1-year mortality in STEMI patients who underwent pPCI but not in-hospital mortality. Reducing the time spent in the emergency department as much as possible may reduce mortality rates.

To assess the impact of triage initiatives for rapid 12-lead electrocardiogram (ECG) acquisition on door-to-ECG (DTE), door-to-balloon (DTB), length of stay (LOS), and in-hospital mortality for self-presenting emergency department (ED) patients with ST-elevation myocardial infarction. This systematic review encompassed cohort studies, controlled trials, one-group pre-test-post-test studies, interventional, observational, and randomized controlled trials assessing rapid acquisition of ECG for patients above 18 years experiencing symptoms of ST-elevation myocardial infarction in ED. Data from seven databases underwent screening, extraction, and quality appraisals by two independent reviewers. Employing a random-effects model, meta-analyses were conducted for primary outcomes: DTE, DTB, LOS, and in-hospital mortality. Subgroup analyses and meta-regression were performed for meta-analyses with over 10 studies. This review included 25 studies with 19 475 ST-elevation myocardial infarction patients. All were cohort studies with acceptable evidence quality. Our findings revealed enhanced triage initiatives for ECG related to significant reductions in DTE (MD -6.45 min, P < 0.001) and DTB (MD -24.40 min, P < 0.001) times. More institutions met benchmarked goals for DTE (MD 22.2%, P < 0.001) and DTB (MD 15.6%, P < 0.001) times. Improvements reported in LOS and in-hospital mortality were not significant. Subgroup and meta-regression analyses revealed significant differences in DTE times, but not in DTB times. Positive impacts of such initiatives on ST-elevation myocardial infarction patient outcomes offer institutions opportunities to improve triage processes and training. Future research should focus on extended follow-up and larger sample sizes for a comprehensive understanding of sustained impacts. PROSPERO: CRD42023472392.

BackgroundTimely activation of primary percutaneous coronary intervention (PCI) is crucial for patients with ST-segment elevation myocardial infarction (STEMI). Door-to-balloon (DTB) time, representing the duration from patient arrival to balloon inflation, is critical for prognosis. However, the specific time segment within the DTB that is most associated with long-term mortality remains unclear. In this study we aimed to identify the target time segment within the DTB that is most associated with one-year mortality in STEMI patients.MethodsWe conducted a retrospective cohort study at a tertiary teaching hospital. All patients diagnosed with STEMI and activated for primary PCI from the emergency department were identified between January 2013–December 2021. Patient demographics, medical history, triage information, electrocardiogram, troponin-I levels, and coronary angiography reports were obtained. We divided the DTB time into door-to-electrocardiogram (ECG), ECG-to-cardiac catheterization laboratory (cath lab) activation, activation-to-cath lab arrival, and cath lab arrival-to-balloon time. We used Kaplan-Meier survival analysis and multivariable Cox proportional hazards models to determine the independent effects of these time intervals on the risk of one-year mortality.ResultsA total of 732 STEMI patients were included. Kaplan-Meier analysis revealed that delayed door-to-ECG time (>10 min) and cath lab arrival-to-balloon time (>30 min) were associated with a higher risk of one-year mortality (log-rank test, P < .001 and P = 0.01, respectively). In the multivariable Cox models, door-to-ECG time was a significant predictor for one-year mortality, whether it was analyzed as a dichotomized (>10 min vs ≤10 min) or a continuous variable. The corresponding adjusted hazard ratios (aHR) were 2.81 (95% confidence interval [CI] 1.42–5.55) for the dichotomized analysis, and 1.03 (95% CI 1.00–1.06) per minute increase, respectively. Cath lab arrival-to-balloon time also showed an independent effect on one-year mortality when analyzed as a continuous variable, with an aHR of 1.02 (95% CI 1.00–1.04) per minute increase. However, ECG-to-cath lab activation and activation-to-cath lab arrival times did not show a significant association with the risk of one-year mortality.ConclusionWithin the door-to-balloon interval, the time from door-to-ECG completion is particularly crucial for one-year survival after STEMI, while cath lab arrival-to-balloon inflation may also be relevant.

Objective: This study aimed to evaluate the impact of door-to-balloon (DTB) time on mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) at Hayatabad Medical Complex, Peshawar. Methodology: A prospective cohort study was conducted with 400 patients divided into two DTB time groups: "&lt;60 minutes" and "60-90 minutes." Patient data, including age, DTB time, and mortality outcomes, were collected over 12 months (April 2022 to March 2023). Statistical analysis involved descriptive summaries and chi-square tests to assess associations between DTB time and mortality, using a p-value of &lt;0.05 for significance. Results: Mortality rates were slightly higher in the "60-90 minutes" group (6.1%) compared to the "&lt;60 minutes" group (5.3%); however, chi-square analysis showed no statistically significant association between DTB time and mortality (\( \chi^2 = 0.07 \), \( p = 0.7849 \)). Age distribution was similar across groups, with no meaningful impact on mortality outcomes. The findings indicate that DTB time alone may not be a sufficient predictor of mortality in this cohort, emphasizing the need for a broader focus on total ischemic time and pre-hospital care. Conclusion: This study suggests that reducing DTB time alone may not significantly affect mortality in STEMI patients, underscoring the need for systemic improvements in pre-hospital and total ischemic time management to optimize patient outcomes.

This systematic review and meta-analysis aimed to summarize the available evidence on the impacts of the COVID-19 pandemic on treatment management, and clinical outcomes among patients with acute coronary syndrome (ACS). PubMed and ScienceDirect were searched from January 2020 to September 2021 to identify relevant studies. For dichotomous variables, meta-analysis was performed using the random-effects model. For continuous variables, descriptive synthesis was conducted. Sixty-three articles were included in the review. The time from symptom onset to First Medical Contact (FMC) was significantly longer during the COVID-19 pandemic in 50% of the studies (17/34). One-third of the studies (9/26) observed significantly longer door-to-balloon (DTB) times during the pandemic. Approximately 73 % of studies (11/15) indicated a significantly longer total ischemic time during the pandemic era. The pooled results did not show a significant difference in in-hospital mortality during the COVID-19 pandemic among patients with ST-elevation myocardial infarction (STEMI) (RD = -0.01, 95% CI -0.02, 0.00) and non-ST-elevation myocardial infarction (NSTEMI) (RD = -0.01, 95% CI -0.01, 0.00). No significant difference in the proportion of patients who underwent Percutaneous Coronary Intervention (PCI) was found across the pandemic period. The COVID-19 pandemic seemed to prolong the time to receive treatment in most settings. Education campaigns and well-planned ACS pathways to ensure timely treatment for patients with ACS during the pandemic/crisis are warranted.

Background Rapid treatment of ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) significantly reduces morbidity and mortality rates. Recent studies emphasize the importance of reducing total ischemic time, making first-medical-contact-to-balloon (FMCTB) time a key performance indicator. To improve FMCTB times in patients brought to the Emergency Department (ED) by Emergency Medical Services (EMS), we implemented a "Direct to Lab" (DTL) workflow during the following conditions: weekday daytime hours, when the lab is fully staffed, and for hemodynamically stable STEMI patients presenting via EMS. Methods We performed a pre/post analysis following the implementation of a pilot workflow for EMS STEMI patients to be rapidly triaged to the cardiac catheterization lab as compared to those patients who underwent the standard workflow before program implementation at a 225-bed community hospital in a suburban setting in Maryland, USA. The hospital's STEMI database was queried from 2/1/2021 through 3/1/2024, including all EMS STEMI alert activations during the study period. Cases were excluded if the patient arrived after program operating hours, declined PCI, or if clinical circumstances (such as cardiac arrest or the need for other resuscitative or diagnostic interventions) necessitated additional ED stabilization before PCI. Results A total of 30 patients met the inclusion criteria. The analysis revealed significantly reduced ED, door-to-balloon (DTB), and FMCTB times for patients under the "Direct to Lab" workflow, including a total ED time of 8.4 minutes faster, an average DTB time of 19.6 minutes faster, and an average FMCTB time of 24.3 minutes faster than those triaged via the standard workflow. Complication rates were similar among both groups. The most common reason that stable patients were not taken directly to the lab was the need for further clinical evaluation before cardiac catheterization or the lab not being immediately available. Conclusion In this pilot single-center analysis, STEMI patients who were expeditiously triaged "Direct to Lab" experienced significantly lower total ED, DTB, and FMCTB times with no difference in procedural complications. This study highlights the patient-centered benefits of a robust collaboration between EMS, ED, and Interventional Cardiology teams.

Introduction: Observational studies have consistently demonstrated a strong association between longer door-to-balloon (DTB) times and increased mortality in patients presenting with ST-elevation myocardial infarction (STEMI). However, the extent to which this association is attributable to unmeasured differences between patients with different DTB times (i.e., confounding), as opposed to a causal impact of longer DTBs is unclear. Aim: In this study, we exploit a natural experiment using an instrumental variable (IV) approach based on weekday vs weekend presentation to evaluate whether incremental delays in DTB times have a causal effect on patient outcomes. Methods: We performed a retrospective analysis of patients undergoing immediate percutaneous coronary intervention (PCI) for STEMI in the CathPCI Registry from 1/2010 to 12/2021 at 1,422 sites. Time of presentation with STEMI (weekday daytime vs weekend daytime) was used as an IV to address potential confounding. A 2-stage IV analysis was used. In-hospital all-cause mortality was the primary outcome. Results: A total of 447,355 patients presented with STEMI during the study period. The average difference in weekend (N=125,787) minus weekday (N=321,568) daytime DTB times was 10.5 minutes. Patient, procedural, and hospital characteristics were well balanced between groups. Overall, in-hospital mortality was 3.5%. In the IV analysis, delays in DTB time were not associated with increased odds of in-hospital mortality (OR 0.99, 95% CI 0.95 to 1.03, P = 0.70). This null association was also observed when limited to hospitals with larger differences (19.5 minutes) between weekend and weekday DTB time (OR 1.00, 95% CI 0.96 to 1.03, P = 0.85) and among patients predicted to have the longest (mean 70.8 minutes) DTB times (OR 1.00, 95% CI 0.94 to 1.07, P = 0.96). Conclusions: Contrary to prior findings, incremental delays in DTB time for patients presenting with STEMI are not associated with increased in-hospital mortality when analyzed using quasi-experimental methods less likely to be influenced by unmeasured confounding. Efforts to further reduce DTB times in patients presenting to hospitals with STEMI are unlikely to improve outcomes. In the current era, policies intended to incentivize better care for STEMI patients should prioritize other measures of quality beyond DTB.

Influence of social factors on prompt reperfusion in patients with ST-segment elevation myocardial infarction: results from the KRAMI multicenter registry

Background COVID-19 became a main health problem and causes heavy impact, especially for healthcare system. Managing ST-Segment Elevation Myocardial Infarction (STEMI) patients before COVID-19 pandemic was already challenging enough for Healthcare Professionals (HCP) to pursue time-sensitive treatment. After COVID-19 pandemic, the time-sensitive treatment of pursuing door-to-balloon (DTB) time put a lot more burden to HCP. In this study, We sought to analyze how a change in protocol of PPCI in STEMI patients before and during the pandemic influence the performance of DTB in the hospital. Methods This is a single-centered retrospective observational study among STEMI patients which was treated by PPCI. Secondary data from the medical record were collected consecutively from April 2018 to January 2022 (46 months). We compared DTB performances before and during the pandemic. Result During 46 months period, the total population of this research was 880 patients. There were total 358 patients underwent PPCI before the pandemic and 522 patients after the pandemic. Modified protocol with the addition step to prevent the spread of COVID-19 had been implemented since April 2020. DTB increased significantly during the pandemic (90 (70-124) minutes vs 97 (76-135) minutes, p 0.002). The proportion of the patients who achieved DTB under 90 min was also significantly decreasing (56.4% vs 47.9%, p 0.0013). Conclusion It is necessary for PPCI center to modify PPCI workflow during the pandemic. A decent workflow should consider practicality and simplicity without compromising HCP and patient safety. Implementing modified PPCI workflow during the pandemic significantly increased DTB time but it is still within the limit of being reasonable and acceptable for the benefit of the patients.

Abstract Background: Chest pain is among the most common reasons patients visit the emergency department (ED). Any new onset of chest pain or any change in the pattern, intensity, or duration of pain in patients with preexisting symptoms must be evaluated to rule out acute coronary syndrome (ACS). Materials and Methods: This study was conducted at the ED of a 250-bed tertiary care center in North India. All patients presenting to the ED with acute chest pain were evaluated using a strictly protocolized approach. The study lasted from October 1, 2021, to December 31, 2022. Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were included in the study. Key timelines recorded included the time of patient arrival, time to electrocardiogram (ECG), time to transfer to the cardiac catheterization laboratory (CCL), and time to catheterization in the CCL. Results: A total of 208 patients presenting to the ED with acute chest pain were diagnosed with STEMI. The mean door-to-ECG time was 2.96 min, door-to-CCL time was 35.02 min, and door-to-balloon (DTB) time was 65.36 min. Additionally, 86.1% of patients had a DTB time of &lt;90 min. Conclusion: STEMI patients are considered the most vulnerable among those with ACS. Nearly three million STEMI cases occur in India each year. Hospitals providing STEMI care can strengthen protocols to meet recommended timelines and ensure better patient care. Utilizing technology and adapting to local needs can help improve STEMI outcomes and contribute to developing an integrated national policy.