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Predictors of door-to-balloon delay in primary angioplasty
Brad G Angeja1, C Michael Gibson, Richard Chin
1Cardiovascular Division, Department of Medicine, the University of California, San Francisco, San Francisco, California 94143, USA. bangeja@medicine.ucsf.edu
Insights
Delayed reperfusion therapy for acute myocardial infarction increases mortality. Hospital transfer, non-daytime presentation, and low-volume centers significantly predict delays in primary percutaneous transluminal coronary angioplasty (pPTCA).
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Delayed reperfusion therapy in acute myocardial infarction (AMI) is linked to higher mortality rates.
- Predictors of treatment delay are established for fibrinolysis but not for primary percutaneous transluminal coronary angioplasty (pPTCA).
Purpose of the Study:
- To identify patient and hospital factors associated with delayed door-to-balloon times in AMI patients undergoing pPTCA.
- To inform strategies for minimizing treatment delays and improving outcomes in AMI.
Main Methods:
- Analysis of 40,017 consecutive AMI patients undergoing pPTCA from the National Registry of Myocardial Infarction (June 1994-April 2000).
- Calculation of median door-to-balloon times.
- Logistic regression to determine factors independently associated with delays exceeding 120 minutes.
Main Results:
- Median door-to-balloon time was 111 minutes; 41% of patients experienced delays >120 minutes.
- Strongest predictors of delay: hospital transfer (87%), non-daytime presentation (51%), and low-volume pPTCA centers (<49/year, 47%).
- Weaker predictors included older age (≥65 years, 49%), female sex (50%), and non-white race.
Conclusions:
- Both patient-specific characteristics and hospital-related factors contribute to delays in pPTCA for AMI.
- Identifying these predictors can guide the development of treatment algorithms to reduce pPTCA delays and enhance survival benefits.
- Findings may also inform future trials on combination reperfusion strategies for AMI.
Abstract:
In the treatment of acute myocardial infarction, delayed reperfusion therapy is associated with increased mortality. Predictors of delay have been described for fibrinolysis but not for primary percutaneous transluminal coronary angioplasty (pPTCA). Therefore, we studied 40,017 consecutive patients with acute myocardial infarction who underwent pPTCA in the National Registry of Myocardial Infarction between June 1994 and April 2000. Median door-to-balloon times were calculated, and factors independently associated with a delay of >120 minutes were determined by logistic regression. The median door-to-balloon time among all patients was 111 minutes (interquartile range 84 to 152). The proportion of patients with a delay of >2 hours was greater among those aged > or = 65 years (49% vs 41%), women (50% vs 42%), patients with contraindications to fibrinolysis (60% vs 41%), and those without chest pain on admission (61% vs 43%, all p <0.0001). Delay was also more common with transfer from another hospital (87% vs 38%), with presentation outside the hours of 8 A.M. to 4 P.M. (51% vs 38%), and in hospitals performing <49 pPTCAs/year (47% vs 41%, all p <0.0001). The strongest independent predictor of delay was hospital transfer, along with non-daytime presentation and low-volume centers. Older age, female sex, and non-white race were weaker predictors. Both patient and hospital factors are associated with delay in pPTCA after presentation. These findings may help design treatment algorithms to minimize delay, thus improving the survival benefit of pPTCA. These results may also help design trials of combination reperfusion strategies.