What is the definition of door (time from hospital arrival to balloon angioplasty) to balloon time in American Heart Association (AHA)/European Society of Cardiology (ESC) guidelines?

Door-to-Balloon Time Definition in AHA/ESC Guidelines

Door-to-balloon (DTB) time is defined as the interval from patient arrival at the emergency department door to the time of first balloon inflation during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). 1

Core Definition Components

The AHA/ACC guidelines establish that door-to-balloon time specifically measures:

• Starting point: Time of arrival at the emergency department door (whether at a PCI-capable or non-PCI-capable hospital) 1
• Endpoint: Time of balloon inflation in the culprit coronary artery during primary PCI 1
• Target goal: ≤90 minutes as a systems goal, not an "ideal" time but rather the longest acceptable time 1

Expanded Time Metrics

The guidelines also define related time intervals that provide context:

First Medical Contact-to-Balloon Time

• Defined as time from EMS arrival on scene (after patient calls 9-1-1) OR time of arrival at the emergency department door (for self-transport) to balloon inflation 1
• This broader metric is increasingly emphasized as it captures the entire healthcare system response 1, 2
• The 90-minute goal applies to this metric as well 1, 2

Door-to-Balloon Time at PCI-Capable Centers

• For patients presenting directly to PCI-capable hospitals: DTB should be <60 minutes according to ESC guidelines 1
• The AHA maintains the 90-minute benchmark but emphasizes achieving faster times when possible 1

Important Distinctions

Door-to-balloon time differs from other reperfusion metrics:

• Door-to-needle time: Measures time from hospital arrival to initiation of fibrinolytic therapy (goal ≤30 minutes) 1, 2
• Door-in to door-out (DI-DO) time: For non-PCI-capable hospitals, measures time from arrival to departure for transfer (goal ≤30 minutes) 1
• EMS arrival-to-balloon time: For patients transported by EMS to PCI-capable hospitals (goal ≤90 minutes) 1, 2

Clinical Context and Caveats

The 90-minute DTB goal is explicitly described as a systems goal rather than an individual patient target 1. This distinction is critical because:

• Individual patient delays may occur due to diagnostic uncertainty, obtaining informed consent, or anatomical challenges during the procedure 1
• These patient-specific factors do not represent quality-of-care failures 1
• However, in the absence of such circumstances, reperfusion should be achieved as rapidly as possible, ideally within 60-70 minutes 1

Recent evidence demonstrates that mortality increases continuously with longer DTB times (30 minutes: 3.0%, 60 minutes: 3.5%, 90 minutes: 4.3%, 120 minutes: 5.6%), suggesting an "as-soon-as-possible" standard rather than accepting 90 minutes as adequate 1. Each 15-minute delay in DTB time is associated with increased mortality risk 1.

Common Pitfalls to Avoid

• Do not interpret the 90-minute goal as a target to aim for—it represents the maximum acceptable time, and systems should strive for much shorter intervals 1
• Do not exclude transferred patients from DTB calculations—the first hospital door-to-balloon time (including transfer time) should still meet the 90-minute goal when possible 1
• Do not delay PCI for extensive diagnostic workup—the focus should be on rapid reperfusion once STEMI is identified 1