From the Guidelines
The difference in coronary artery anatomy does not directly impact door-to-balloon time targets of 90 versus 60 minutes in patients with ST-elevation myocardial infarction (STEMI). Door-to-balloon time is primarily influenced by healthcare system factors rather than patient anatomy. These factors include emergency department efficiency, catheterization lab readiness, team communication, and hospital protocols. While complex coronary anatomy (such as tortuous vessels, calcified lesions, chronic total occlusions, or bifurcation lesions) may increase the procedural time once the catheterization begins, this occurs after the patient has already reached the lab and thus doesn't affect the door-to-balloon metric.
The 90-minute target is the current standard recommendation for STEMI patients, as stated in the ACC/AHA/SCAI guidelines 1, while the 60-minute goal represents an ideal target for optimized systems. Both timeframes aim to minimize myocardial damage by restoring blood flow as quickly as possible, as each 30-minute delay in reperfusion increases mortality risk by approximately 8% 1. Hospitals should focus on streamlining their STEMI protocols rather than selecting patients based on anticipated coronary anatomy complexity.
Some key considerations for achieving optimal door-to-balloon times include:
- Emergency department efficiency
- Catheterization lab readiness
- Team communication
- Hospital protocols
- Systems approach for rapid triage and transfer
- Transporting patients directly to PCI centers, rather than transporting them to the nearest hospital, if interhospital transfer will subsequently be required to obtain primary PCI 1.
Given the importance of timely reperfusion in patients who undergo primary PCI, the goal should be to achieve a door-to-balloon time within 90 minutes, as recommended by the ACC/AHA/SCAI guidelines 1. This goal is crucial for minimizing myocardial damage and reducing mortality risk in STEMI patients.
From the Research
Coronary Artery Anatomy and Door-to-Balloon Time
The difference in coronary artery anatomy between patients achieving a door-to-balloon time of 90 minutes versus 60 minutes is not explicitly stated in the provided studies. However, the studies suggest that shorter door-to-balloon times are associated with better clinical outcomes.
Clinical Outcomes and Door-to-Balloon Time
- A study published in the Journal of Cardiology in 2023 found that shorter door-to-balloon times were associated with better long-term clinical outcomes in STEMI patients treated with primary percutaneous coronary intervention 2.
- A study published in the Journal of the American Heart Association in 2019 found that reducing door-to-balloon time was significantly associated with survival benefit, and the survival benefit of shortening door-to-balloon time was consistently observed, even <60 to 90 minutes 3.
- A study published in the New England Journal of Medicine in 2006 identified hospital strategies that were significantly associated with a faster door-to-balloon time, including having emergency medicine physicians activate the catheterization laboratory and having a single call to a central page operator activate the laboratory 4.
- A study published in BMJ Quality Improvement Reports in 2015 found that implementing the Lean Six Sigma methodology resulted in a decreased median door-to-balloon time from 75.9 minutes to 60.1 minutes, and the percentage of patients who underwent PCI within 90 minutes increased from 73% to 96% 5.
Door-to-Balloon Time and Coronary Artery Anatomy
While the provided studies do not directly address the difference in coronary artery anatomy between patients achieving a door-to-balloon time of 90 minutes versus 60 minutes, a study published in Circulation Journal in 2009 mentions that early percutaneous coronary intervention appears to be beneficial when performed in a timely manner with a door-to-balloon time <90 min, suggesting that timely reperfusion therapy may have an impact on coronary artery anatomy 6. However, more research is needed to fully understand the relationship between door-to-balloon time and coronary artery anatomy.