What are the door‑to‑balloon times, access‑site usage, in‑hospital and long‑term mortality, and major adverse cardiac event rates for primary percutaneous coronary intervention (PCI) in ST‑elevation myocardial infarction patients across Asian countries?

Primary PCI Performance in Asia: Data and Outcomes

Door-to-Balloon Times and Access-Site Usage

Asian centers demonstrate variable but generally acceptable door-to-balloon times, with radial access adoption lagging behind European standards but exceeding African practices. 1

• In a global survey of primary PCI practices, Asian operators reported performing primary PCI in high-volume centers (>200 procedures annually), comparable to European and Latin American counterparts. 1
• Radial arterial access was utilized in approximately 85% of primary PCI cases in Asia, significantly higher than Africa (53%) but lower than Europe (98%). 1
• The majority of Asian interventional cardiologists (85%) routinely pretreat STEMI patients with P2Y12 inhibitors before or at the time of PCI, matching European practices (82%). 1
• Left ventriculography was performed less frequently in Asia (6%) compared to Latin America (25%) and Africa (20%), suggesting more streamlined procedural approaches. 1

Procedural Success and In-Hospital Mortality

Asian primary PCI programs achieve high procedural success rates (>96%) with in-hospital mortality rates of 12-13% overall, though non-shock mortality remains low at 2-3%. 2

• A North Indian tertiary care center reported 96.4% successful primary PCI completion in 371 consecutive STEMI patients. 2
• Overall in-hospital mortality was 12.9%, but this figure was heavily influenced by cardiogenic shock cases (66.7% mortality with shock versus 2.6% without shock). 2
• The mean total ischemic time was 6.8 hours, with door-to-balloon time averaging 51 minutes—well within the recommended 90-minute target. 2
• TIMI 3 flow was achieved in 96.4% of cases, comparable to Western benchmarks. 2

Major Adverse Cardiac Events (MACE)

In-hospital MACE rates in Asian STEMI cohorts range from 13-14%, with procedure-related complications remaining rare. 2

• The composite endpoint of in-hospital mortality, non-fatal reinfarction, and stroke occurred in 13.5% of patients in the North Indian registry. 2
• Non-CABG-related major TIMI bleeding was absent in this cohort, and procedure-related adverse events were rare. 2
• Independent predictors of mortality included Killip class (OR 8.4), door-to-balloon time (OR 1.02 per minute), final TIMI flow (OR 0.44), and severe left ventricular dysfunction (OR 22.0). 2

Regional Variations in Practice Patterns

Asian operators demonstrate distinct practice patterns, particularly in the timing of non-culprit lesion revascularization and use of adjunctive techniques. 1

• Unlike European and Latin American centers that typically complete non-culprit lesion revascularization during the index procedure or before discharge, Asian centers more commonly defer this to post-discharge staged procedures. 1
• Aspiration thrombectomy practices varied significantly across Asian centers, with no uniform protocol for its application. 1
• High-volume Asian operators (>75 primary PCIs annually) were more likely to work in 24/7 PCI-capable hospitals and routinely perform radial access procedures. 1

High-Risk Subgroups: Unprotected Left Main STEMI

Asian centers participating in the ASTER registry demonstrated that unprotected left main STEMI carries exceptionally high mortality (47.8%) despite primary PCI. 3

• In a multicenter Asia-Pacific registry including Singapore and South Korea, 67 patients with unprotected left main STEMI underwent emergency PCI. 3
• Post-PCI TIMI 3 flow was achieved in 76% of cases, but in-hospital mortality remained 47.8%. 3
• Independent predictors of mortality included older age (OR 1.085), diabetes mellitus (OR 10.882), and absence of post-PCI TIMI 3 flow (OR 71.429). 3
• Major complications included cardiac failure (61%), malignant ventricular arrhythmias (55%), emergency CABG (4%), stroke (3%), and reinfarction (1%). 3

Time-Dependent Outcomes

Reducing symptom-onset-to-hospital-arrival time remains the most critical modifiable factor for improving Asian STEMI outcomes. 4

• In a 96-patient Iraqi cohort, patients who died had significantly longer symptom-onset-to-hospital times (6.92 ± 3.86 hours) compared to survivors (3.61 ± 1.67 hours, P<0.001). 4
• In-hospital mortality was 11.2% with 30-day mortality of 2.3% in this Middle Eastern cohort. 4
• Additional independent predictors of mortality included atypical presentation, cardiogenic shock, chronic kidney disease, TIMI 0/1/2 flow, triple-vessel disease, ventricular arrhythmias, coronary dissection, and no-reflow phenomenon. 4

Quality Improvement Opportunities

Asian primary PCI programs demonstrate room for improvement, particularly in standardizing procedural techniques and expanding 24/7 access. 1, 5

• Regional STEMI networks with prehospital ECG recording, early diagnosis, and direct catheterization laboratory referral have proven effective in reducing treatment delays globally and should be more widely implemented in Asia. 5
• The variation in aspiration thrombectomy use and non-culprit lesion management suggests a need for more uniform evidence-based protocols. 1
• Expanding radial access adoption from 85% toward the 98% achieved in Europe would further reduce bleeding complications. 1