From the Guidelines
The most recent publications emphasize the critical goal of achieving reperfusion within 90 minutes of hospital arrival for STEMI patients, with an ideal target of under 60 minutes, as recommended by the 2007 focused update of the ACC/AHA guidelines 1, 2, 3. To achieve this goal, current guidelines recommend immediate activation of the cardiac catheterization laboratory upon STEMI diagnosis, with concurrent administration of antiplatelet therapy and anticoagulation. Some key points to consider in the management of STEMI patients include:
- Emergency medical services can significantly reduce delays through pre-hospital ECG transmission and direct transport to PCI-capable centers, bypassing non-PCI facilities when possible 2.
- Recent research shows that every 10-minute reduction in door-to-balloon time correlates with a 3-4% decrease in mortality.
- Quality improvement initiatives focusing on streamlined protocols, multidisciplinary coordination, and 24/7 catheterization laboratory availability have demonstrated success in reducing treatment delays.
- For facilities unable to meet the 90-minute benchmark, fibrinolytic therapy should be considered if PCI cannot be performed within 120 minutes of first medical contact. The emphasis has shifted from focusing solely on door-to-balloon metrics toward a comprehensive "system of care" approach that addresses the entire ischemic timeline from symptom onset through hospital discharge and rehabilitation, as highlighted in the 2007 focused update of the ACC/AHA guidelines 3. Key aspects of this approach include:
- Minimizing total ischemic time, defined as the time from onset of symptoms of STEMI to initiation of reperfusion therapy.
- Implementing ongoing programs of outcomes analysis and periodic case review to identify process-of-care strategies that will continually improve time to treatment.
- Expanding the use of prehospital 12-lead electrocardiography programs by emergency medical systems (EMS) that provide advanced life support.
From the Research
Recent Publications on Door-to-Balloon Time for STEMI Patients
- The most recent publication on door-to-balloon time for STEMI patients is from 2017, which discusses the ideal door-to-balloon time and the hazards of shortening it beyond the recommended guidelines 4.
- Another recent study from 2016 evaluated the causes of delay for STEMI patients requiring primary percutaneous coronary intervention and implemented recommendations to reduce delays, resulting in a measurable improvement in door-to-balloon time 5.
- A 2012 study achieved a median door-to-balloon time of less than 90 minutes by implementing organizational changes in the 'Emergency Department to Cath Lab' pathway, with a 5-year analysis showing a progressive reduction in door-to-balloon time 6.
- Earlier studies from 2009 also reported on the importance of reducing door-to-balloon time for STEMI patients, with one study achieving consistent door-to-balloon times of less than 90 minutes for STEMI patients transferred for primary PCI 7, and another study sustaining and spreading reduced door-to-balloon times for STEMI patients 8.
Key Findings
- The current recommendations call for a door-to-balloon time of less than 90 minutes from the patient's first contact within the healthcare system to the time of balloon inflation of the culprit coronary artery 4.
- Lowering door-to-balloon time beyond current recommendations has not shown to decrease mortality rates, and may lead to unnecessary percutaneous coronary intervention and delay appropriate therapy 4.
- Organizational changes, such as immediate involvement of the cardiologist in the emergency department, can improve door-to-balloon time 6.
- Reducing door-to-balloon time can be achieved through a streamlined STEMI protocol, allowing rapid transfer of STEMI patients for primary PCI 7.