Door-to-Balloon Time and Mortality Among Patients Undergoing Primary PCI

Study Questions:

What is the impact of national improvements in door-to-balloon times on mortality?

Methods:

The investigators analyzed annual trends in door-to-balloon times and in-hospital mortality using data from 96,738 admissions for patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) from July 2005 through June 2009, at 515 hospitals participating in the CathPCI Registry. In a subgroup analysis using a linked Medicare data set, they assessed 30-day mortality. Multivariable model analyses were performed with in-hospital mortality as the dependent variable in a logistic-regression model, and door-to-balloon time as the dependent variable in a linear-regression model.

Results:

Median door-to-balloon times declined significantly, from 83 minutes in the 12 months from July 2005 through June 2006, to 67 minutes in the 12 months from July 2008 through June 2009 (p < 0.001). Similarly, the percentage of patients for whom the door-to-balloon time was 90 minutes or less increased from 59.7% in the first year to 83.1% in the last year (p < 0.001). Despite improvements in door-to-balloon times, there was no significant overall change in unadjusted in-hospital mortality (4.8% in 2005-2006 and 4.7% in 2008-2009, p = 0.43 for trend), or in risk-adjusted in-hospital mortality (5.0% in 2005-2006 and 4.7% in 2008-2009, p = 0.34), nor was a significant difference observed in unadjusted 30-day mortality (p = 0.64).

Conclusions:

The authors concluded that although national door-to-balloon times have improved significantly for patients undergoing primary PCI for STEMI, in-hospital mortality has remained virtually unchanged.

Perspective:

This study reported that despite significant reductions in door-to-balloon times across the United States, overall unadjusted and risk-adjusted in-hospital mortality has remained virtually unchanged. The study findings raise questions about the role of door-to-balloon time as a principal focus for performance measurement and public reporting. It appears that additional factors will need to be targeted to accomplish further reductions in mortality. These would include increasing patients’ awareness of symptoms, reducing the interval from the time of symptom onset to treatment, shortening the transfer time between medical facilities, and improvement and optimization of both in-hospital and postdischarge care.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Registries, Myocardial Infarction, Hospital Mortality, Cardiology, Cardiovascular Diseases, Medicare, Angioplasty, Linear Models, Myocardial Reperfusion, Logistic Models, United States, Percutaneous Coronary Intervention


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