Door-to-Balloon Time for Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

Abstract

Ιt has become clear, recently, that reperfusion by primary coronary intervention in patients with ST elevation myocardial infarction (STEMI) is superior to thrombolytic therapy and is the treatment of choice. However, this reperfusion strategy has some drawbacks, as cardiac catheterization laborato-ries are not always widely available 24h/7d and long-time delays related to primary percutaneous coronary intervention (pPCI) may have negative impact on mortality. The shorter the delay from symptom onset to reperfusion, the greater the amount of the myocardium rescued as it is obvious that “time is muscle”. Among pPCI related times the crucial time delay is the one from door–to-balloon (time from arrival at the hospital until the mechanical restoration of the vessel patency).This time delay is usually accurately recorded and depends on the national (or even local) health care system. The European Society of Cardiology guidelines on myocardial revascularization suggest that total ischemic time should not exceed 120min and especially 90min for patients <65 years old, with anterior infarction and early presentation (<2h) from onset of symptoms, because these categories of patients have even worse outcomes and increased mortality with prolonged door-to-balloon times, compared to other categories.

Better patient education about symptoms suggesting myocardial ischaemia, pre-hospital diagnosis of STEMI based on 12-lead electrocardiogram with immediate transportation to a PCI-capable centre in order to eliminate inter-hospital delays, an effective emergency medical system capable of quick transportation, immediate activation of the cardiac catheterization laboratory from emergency physicians or an attendant cardiologist, the presence of an experienced team of high volume operators and skilled supporting staff capable of performing pPCI 24h/7d, new and more effective antithrombotic drugs and angioplasty materials, are the key elements to achieve shorter door-to-balloon and PCI delay times and therefore rescue the greater amount of myocardium and reduce mortality.