Critical Time Intervals in Door-to-Balloon Time Linked to One-Year Mortality in ST-Elevation Myocardial Infarction
Shin-Ho Tsai1, Yu-Ting Hsiao1, Ya-Ni Yeh1
1Ditmanson Medical Foundation Chia-Yi Christian Hospital, Department of Emergency Medicine, Chiayi City, Taiwan.
Insights
For ST-segment elevation myocardial infarction (STEMI) patients, the time from hospital arrival to electrocardiogram (ECG) completion is critical for one-year survival. Minimizing this door-to-ECG interval improves outcomes after primary percutaneous coronary intervention (PCI).
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Primary percutaneous coronary intervention (PCI) is vital for ST-segment elevation myocardial infarction (STEMI) patients.
- Door-to-balloon (DTB) time is a key prognostic indicator, but specific critical intervals within DTB are not well-defined.
- Understanding which time segment most impacts long-term mortality is essential for optimizing STEMI care pathways.
Purpose of the Study:
- To identify the specific time segment within the door-to-balloon (DTB) interval most associated with one-year mortality in STEMI patients.
- To determine if door-to-electrocardiogram (ECG) time, ECG-to-cath lab activation, activation-to-cath lab arrival, or cath lab arrival-to-balloon time significantly predicts long-term outcomes.
Main Methods:
- Retrospective cohort study of 732 STEMI patients undergoing primary PCI from January 2013 to December 2021.
- DTB time was segmented into door-to-ECG, ECG-to-cath lab activation, activation-to-cath lab arrival, and cath lab arrival-to-balloon intervals.
- Kaplan-Meier survival analysis and multivariable Cox proportional hazards models were used to assess the impact of time intervals on one-year mortality.
Main Results:
- Delayed door-to-ECG time (>10 min) and cath lab arrival-to-balloon time (>30 min) were associated with increased one-year mortality.
- Door-to-ECG time independently predicted one-year mortality, with adjusted hazard ratios of 2.81 (dichotomized) and 1.03 per minute (continuous).
- Cath lab arrival-to-balloon time also independently predicted mortality (aHR 1.02 per minute), while other intervals showed no significant association.
Conclusions:
- The time from hospital arrival to ECG completion (door-to-ECG) is a critical determinant of one-year survival in STEMI patients.
- Cath lab arrival-to-balloon time may also influence long-term outcomes.
- Optimizing the initial diagnostic phase (door-to-ECG) is paramount for improving survival post-STEMI.
Background:
Timely activation of primary percutaneous coronary intervention (PCI) is crucial for patients with ST-segment elevation myocardial infarction (STEMI). Door-to-balloon (DTB) time, representing the duration from patient arrival to balloon inflation, is critical for prognosis. However, the specific time segment within the DTB that is most associated with long-term mortality remains unclear. In this study we aimed to identify the target time segment within the DTB that is most associated with one-year mortality in STEMI patients.
Methods:
We conducted a retrospective cohort study at a tertiary teaching hospital. All patients diagnosed with STEMI and activated for primary PCI from the emergency department were identified between January 2013-December 2021. Patient demographics, medical history, triage information, electrocardiogram, troponin-I levels, and coronary angiography reports were obtained. We divided the DTB time into door-to-electrocardiogram (ECG), ECG-to-cardiac catheterization laboratory (cath lab) activation, activation-to-cath lab arrival, and cath lab arrival-to-balloon time. We used Kaplan-Meier survival analysis and multivariable Cox proportional hazards models to determine the independent effects of these time intervals on the risk of one-year mortality.
Results:
A total of 732 STEMI patients were included. Kaplan-Meier analysis revealed that delayed door-to-ECG time (>10 min) and cath lab arrival-to-balloon time (>30 min) were associated with a higher risk of one-year mortality (log-rank test, P < .001 and P = 0.01, respectively). In the multivariable Cox models, door-to-ECG time was a significant predictor for one-year mortality, whether it was analyzed as a dichotomized (>10 min vs ≤10 min) or a continuous variable. The corresponding adjusted hazard ratios (aHR) were 2.81 (95% confidence interval [CI] 1.42-5.55) for the dichotomized analysis, and 1.03 (95% CI 1.00-1.06) per minute increase, respectively. Cath lab arrival-to-balloon time also showed an independent effect on one-year mortality when analyzed as a continuous variable, with an aHR of 1.02 (95% CI 1.00-1.04) per minute increase. However, ECG-to-cath lab activation and activation-to-cath lab arrival times did not show a significant association with the risk of one-year mortality.
Conclusion:
Within the door-to-balloon interval, the time from door-to-ECG completion is particularly crucial for one-year survival after STEMI, while cath lab arrival-to-balloon inflation may also be relevant.
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