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Door-to-balloon delays with PCI in acute myocardial infarction

Current Treatment Options in Cardiovascular Medicine volume 6, pages 69–77 (2004)Cite this article

Opinion statement

In the treatment of acute myocardial infarction (AMI), the length of time from symptom onset to revascularization is a crucial determinant of clinical outcomes such as mortality and reinfarction. Direct, or primary, percutaneous transluminal coronary angioplasty (PTCA) produces higher rates of infarct-related artery patency and improved clinical outcomes compared to thrombolytic therapy. However, primary PTCA is associated with an increased time interval from hospital arrival to revascularization, the so-called door-to-balloon time. Numerous data support the theory that increased door-to-balloon time reduces the benefits of primary PTCA in the treatment of AMI. Therefore, institutions that offer PTCA must strive to decrease door-to-balloon delays through the use of established treatment protocols and frequent assessment of performance.

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References and Recommended Reading

  1. Braunwald E: The open artery theory is alive and well again. N Engl J Med 1993, 329:1650–1652.

    PubMed  Article  CAS  Google Scholar 

  2. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group [no authors listed]. Lancet 1994, 343:311–322.

  3. Goldberg RJ, Mooradd M, Gurwitz JH, et al.: Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (The second National Registry of Myocardial Infarction). Am J Cardiol 1998, 82:259–264.

    PubMed  Article  CAS  Google Scholar 

  4. Newby LK, Rutsch WR, Califf RM, et al.: Time from symptom onset to treatment and outcomes after thrombolytic therapy. The GUSTO-1 Investigators. J Am Coll Cardiol 1996, 27:1646–1655.

    PubMed  Article  CAS  Google Scholar 

  5. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. The GUSTO investigators [no authors listed]. N Engl J Med 1993, 329:673–682.

  6. The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators [no authors listed]. N Engl J Med 1993, 329:1615–1622.

  7. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. GUSTO IIb investigators [no authors listed]. N Engl J Med 1997, 336:1621–1628.

  8. Grines CL, Cox DA, Stone GW, et al.: Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1999, 341:1949–1956.

    PubMed  Article  CAS  Google Scholar 

  9. Bode C, Smalling RW, Berg G, et al.: Randomized comparison of coronary thrombolysis achieved with doublebolus reteplase (recombinant plasminogen activator) and front-loaded, accelerated alteplase (recombinant tissue plasminogen activator) in patients with acute myocardial infarction. The RAPID II Investigators. Circulation 1996, 94:891–898.

    PubMed  CAS  Google Scholar 

  10. Cannon CP, Gibson CM, McCabe CH, et al.: TNK-tissue plasminogen activator compared with front-loaded alteplase in acute myocardial infarction: results of the TIMI 10B trial. Thrombolysis in Myocardial Infarction (TIMI) 10B Investigators. Circulation 1998, 98:2805–2814.

    PubMed  CAS  Google Scholar 

  11. Weaver WD, Simes RJ, Betriu A, et al.: Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA 1997, 278:2093–2098.

    PubMed  Article  CAS  Google Scholar 

  12. Keeley EC, Boura JA, Grines CL: Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003, 361:13–20.

    PubMed  Article  Google Scholar 

  13. Cannon CP, Antman EM, Walls R, Braunwald E: Time as an adjunctive agent to thrombolytic therapy. J Thromb Thrombolysis 1994, 1:27–34.

    PubMed  Article  Google Scholar 

  14. Rogers WJ, Dean LS, Moore PB, et al.: Comparison of primary angioplasty versus thrombolytic therapy for acute myocardial infarction. Alabama Registry of Myocardial Ischemia Investigators. Am J Cardiol 1994, 74:111–118.

    PubMed  Article  CAS  Google Scholar 

  15. Every NR, Parsons LS, Hlatky M, et al.: A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. Myocardial Infarction Triage and Intervention Investigators. N Engl J Med 1996, 335:1253–1260.

    PubMed  Article  CAS  Google Scholar 

  16. Grines CL, Browne KF, Marco J, et al.: A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1993, 328:673–679.

    PubMed  Article  CAS  Google Scholar 

  17. Zijlstra F, de Boer MJ, Hoorntje JC, et al.: A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993, 328:680–684.

    PubMed  Article  CAS  Google Scholar 

  18. Braunwald E: Optimizing thrombolytic therapy of acute myocardial infarction. Circulation 1990, 82:1510–1513.

    PubMed  CAS  Google Scholar 

  19. Cannon CP: Time to treatment: a crucial factor in thrombolysis and primary angioplasty. J Thromb Thrombolysis 1996, 3:249–255.

    PubMed  Google Scholar 

  20. Brodie BR, Stuckey TD, Wall TC, et al.: Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 1998, 32:1312–1319.

    PubMed  Article  CAS  Google Scholar 

  21. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators [no authors listed]. N Engl J Med 1997, 336:1621–1628.

  22. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb investigators [no authors listed]. N Engl J Med 1996, 335:775–782.

  23. Berger PB, Ellis SG, Holmes DR Jr, et al.: Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial. Circulation 1999, 100:14–20.

    PubMed  CAS  Google Scholar 

  24. Cannon CP, Gibson CM, Lambrew CT, et al.: Relationship of symptom-onset-to-balloon time and door-toballoon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA 2000, 283:2941–2947. Large retrospective database analysis that provides strong evidence that door-to-balloon delays are a crucial determinant of clinical outcomes in AMI.

    PubMed  Article  CAS  Google Scholar 

  25. Rubin DB: Estimating causal effects from large data sets using propensity scores. Ann Intern Med 1997, 127:757–763.

    PubMed  CAS  Google Scholar 

  26. Joffe MM, Rosenbaum PR: Invited commentary: propensity scores. Am J Epidemiol 1999, 150:327–333.

    PubMed  CAS  Google Scholar 

  27. Ryan TJ, Anderson JL, Antman EM, et al.: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996, 28:1328–1428.

    PubMed  Article  CAS  Google Scholar 

  28. Ryan TJ, Antman EM, Brooks NH, et al.: 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1999, 34:890–911.

    PubMed  Article  CAS  Google Scholar 

  29. Brodie BR, Stone GW, Morice MC, et al.: Importance of time to reperfusion on outcomes with primary coronary angioplasty for acute myocardial infarction (results from the Stent Primary Angioplasty in Myocardial Infarction Trial). Am J Cardiol 2001, 88:1085–1090.

    PubMed  Article  CAS  Google Scholar 

  30. Antoniucci D, Valenti R, Migliorini A, et al.: Relation of time to treatment and mortality in patients with acute myocardial infarction undergoing primary coronary angioplasty. Am J Cardiol 2002, 89:1248–1252.

    PubMed  Article  Google Scholar 

  31. Brodie BR, Stuckey TD, Muncy DB, et al.: Importance of time-to-reperfusion in patients with acute myocardial infarction with and without cardiogenic shock treated with primary percutaneous coronary intervention. Am Heart J 2003, 145:708–715.

    PubMed  Article  Google Scholar 

  32. Caputo RP, Ho KK, Stoler RC, et al.: Effect of continuous quality improvement analysis on the delivery of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction. Am J Cardiol 1997, 79:1159–1164.

    PubMed  Article  CAS  Google Scholar 

  33. Ward MR, Lo ST, Herity NA, et al.: Effect of audit on door-to-inflation times in primary angioplasty/stenting for acute myocardial infarction. Am J Cardiol 2001, 87:336–338, A339. Demonstrates improvement in door-to-balloon times after an audit of established protocols in a primary angioplasty center.

    PubMed  Article  CAS  Google Scholar 

  34. Shry EA, Eckart RE, Winslow JB, et al.: Effect of monitoring of physician performance on door-to-balloon time for primary angioplasty in acute myocardial infarction. Am J Cardiol 2003, 91:867–869. Illustrates a reduction in door-to-balloon times by passive monitoring alone.

    PubMed  Article  Google Scholar 

  35. Canto JG, Rogers WJ, Bowlby LJ, et al.: The prehospital electrocardiogram in acute myocardial infarction: is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators. J Am Coll Cardiol 1997, 29:498–505.

    PubMed  Article  CAS  Google Scholar 

  36. Lenfant C, LaRosa JH, Horan MJ, Passamani ER: Considerations for a national heart attack alert program. Clin Cardiol 1990, 13:VIII9-VIII11.

    PubMed  CAS  Google Scholar 

  37. Emergency department: rapid identification and treatment of patients with acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment Working Group [no authors listed]. Ann Emerg Med 1994, 23:311–329.

  38. 9-1-1: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee [no authors listed]. Am J Emerg Med 1995, 13:188–195.

  39. Emergency medical dispatching: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee [no authors listed]. Am J Emerg Med 1995, 13:67–73.

  40. Staffing and equipping emergency medical services systems: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee [no authors listed]. Am J Emerg Med 1995, 13:58–66.

  41. Krall SP, Reese CLT, Donahue L: Effect of continuous quality improvement methods on reducing triage to thrombolytic interval for acute myocardial infarction. Acad Emerg Med 1995, 2:603–609.

    PubMed  CAS  Google Scholar 

  42. Hand M, Brown C, Horan M, Simons-Morton D: The National Heart Attack Alert Program: progress at 5 years in educating providers, patients, and the public and future directions. J Thromb Thrombolysis 1998, 6:9–17.

    PubMed  Article  Google Scholar 

  43. Cannon CP, Johnson EB, Cermignani M, et al.: Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction. Clin Cardiol 1999, 22:17–20.

    PubMed  CAS  Article  Google Scholar 

  44. Zalenski RJ, Selker HP, Cannon CP, et al.: National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia. Ann Emerg Med 2000, 35:462–471.

    PubMed  CAS  Google Scholar 

  45. Karagounis L, Ipsen SK, Jessop MR, et al.: Impact of field-transmitted electrocardiography on time to inhospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990, 66:786–791.

    PubMed  Article  CAS  Google Scholar 

  46. Weaver WD, Eisenberg MS, Martin JS, et al.: Myocardial Infarction Triage and Intervention Project—phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coll Cardiol 1990, 15:925–931.

    PubMed  CAS  Article  Google Scholar 

  47. Kereiakes DJ, Gibler WB, Martin LH, et al.: Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati Heart Project. Am Heart J 1992, 123:835–840.

    PubMed  Article  CAS  Google Scholar 

  48. Magid DJ, Calonge BN, Rumsfeld JS, et al.: Relation between hospital primary angioplasty volume and mortality for patients with acute MI treated with primary angioplasty vs thrombolytic therapy. JAMA 2000, 284:3131–3138.

    PubMed  Article  CAS  Google Scholar 

  49. Canto JG, Every NR, Magid DJ, et al.: The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators. N Engl J Med 2000, 342:1573–1580.

    PubMed  Article  CAS  Google Scholar 

  50. Angeja BG, Gibson CM, Chin R, et al.: Predictors of door-to-balloon delay in primary angioplasty. Am J Cardiol 2002, 89:1156–1161. Analysis of predictors of door-to-balloon delays in a large national AMI database.

    PubMed  Article  Google Scholar 

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Affiliations

  1. TIMI Data Coordinating Center and Angiographic Core Laboratory, 350 Longwood Avenue, First Floor, 02115, Boston, MA, USA

    C. Michael Gibson MS, MD

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  1. Daniel R. Guerra MD
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  2. C. Michael Gibson MS, MD
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Guerra, D.R., Gibson, C.M. Door-to-balloon delays with PCI in acute myocardial infarction. Curr Treat Options Cardio Med 6, 69–77 (2004). https://doi.org/10.1007/s11936-004-0016-5

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  • DOI: https://doi.org/10.1007/s11936-004-0016-5

Keywords

  • Percutaneous Coronary Intervention
  • Acute Myocardial Infarction
  • Acute Myocardial Infarction
  • Thrombolytic Therapy
  • Acute Myocardial Infarction Patient