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Myocardial Infarction
Time Is of the Essence—A Review of Evidence to Support Rapid Discovery to
Treatment for Patients with ST-segment Elevation Myocardial Infarction
Joris van den Hurk
Vice President, Cardiology Care Cycles, Philips Healthcare
Abstract
This article examines the evidence supporting the decision taken by European and US professional bodies to reduce recommended target
treatment times for patients experiencing an ST-segment elevation myocardial infarction (STEMI) with primary percutaneous coronary
intervention (PCI). The guideline states that primary PCI should be performed on patients presenting with STEMI as soon as possible, with a
target of medical-contact-to-balloon or door-to-balloon time of ≤90 minutes. The challenges that hospitals/care-givers face in meeting this
guideline are outlined, together with successful strategies that have been employed. Research shows factors that are associated with improved
door-to-balloon standards, steps taken to increase these standards, and why meeting this guideline is still uncommon in Europe and the US. In
conclusion, the strategies, protocols, and technologies that enable implementation of this guideline are considered to be available; however,
best practice and technology need to be brought closer together in order to improve overall care for patients with STEMI.
Keywords
ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI), contact-to-balloon time, door-to-balloon time,
best practice, protocols, standards, guideline
Disclosure: Joris van den Hurk is Vice President of Cardiology Care Cycles at Philips Healthcare.
Received: December 4, 2008 Accepted: December 18, 2008
Correspondence: Joris van den Hurk, Vice President, Cardiology Care Cycles, Philips Healthcare, Best, The Netherlands. E:
joris.van.den.hurk@philips.com
Cardiovascular disease (CVD) is the most common cause of death adjustment for baseline characteristics, time from symptom onset to
worldwide.
1
With an estimated 7.6 million global deaths due to balloon inflation is significantly correlated with one-year mortality in
coronary heart disease in 2005,
2
the size of the burden placed on patients undergoing primary PCI for STEMI. With each 30-minute delay
society cannot be understated. Acute myocardial infarction (AMI), the between symptom onset and balloon inflation, risk for patient
classic ‘heart attack,’ will be the classification given to many of these mortality increases by 7.5%.
7
Of particular importance to this
deaths. In its most life-threatening form, AMI is identified with discussion is our knowledge that the mortality benefits of primary PCI
ST-segment elevation myocardial infarction (STEMI) indicated via over thrombolytic therapy are especially dependent on ‘door-to-
12-lead echocardiography (ECG). Primary percutaneous coronary balloon time’ (defined as the interval between arrival at the hospital
intervention (PCI) has been shown to demonstrate superior clinical and intracoronary balloon inflation). Researchers of an observational
outcomes for patients presenting with STEMI in terms of its ability to study involving 661 community and tertiary care hospitals in the US
achieve higher patency rates, minimize infarct size, and improve left found that door-to-balloon times significantly increased the adjusted
ventricular function and long-term survival (as well as lower rates of odds of in-hospital mortality (41–62% for patients with door-to-
reinfarction and stroke compared with thrombolytic therapy).
3,4
As a balloon times >120 minutes), whereas mortality did not increase
result, more than 500,000 PCI procedures are performed yearly in the significantly with increasing delay from onset of symptoms to first
US alone,
5
and it has been estimated that more than one million balloon inflation.
8
procedures are performed annually worldwide.
6
However, although
primary PCI is highly effective, as with other treatments its efficacy is Similarly, a cohort study of 29,222 STEMI patients treated with PCI
also time-dependent. within six hours of presentation at 395 US hospitals participating in
the National Registry of Myocardial Infarction (NRMI) reported that
Clinical Evidence longer door-to-balloon time was associated with increased in-hospital
For all forms of PCI in STEMI, there is undisputed agreement that mortality.
9
Adjusted for patient characteristics, patients with door-to-
every effort must be made to minimize the interval time between balloon time >90 minutes had increased mortality (odds ratio 1.42;
onset of chest pain or other symptoms and the initiation of a safe and 95% confidence interval [CI] 1.24–1.62) compared with those who had
effective reperfusion strategy, known as ‘total ischemia time.’ After a door-to-balloon time of ≤90 minutes. The authors concluded that
62 © TOUCH BRIEFINGS 2009
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