title: Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy.
abstract: BACKGROUND
  It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.
  
  
  RESULTS
  DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192,509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.
  
  
  CONCLUSIONS
  As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
authors.affiliation: TIMI Study Group and the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA 02115, USA.
authors.forename: Duane S
authors.initials: DS
authors.lastname: Pinto
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.forename: Sabina A
authors.initials: SA
authors.lastname: Murphy
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
authors.forename: Roger J
authors.initials: RJ
authors.lastname: Laham
authors.forename: Donald E
authors.initials: DE
authors.lastname: Cutlip
authors.forename: Eric R
authors.initials: ER
authors.lastname: Bates
authors.forename: Paul D
authors.initials: PD
authors.lastname: Frederick
authors.forename: Dave P
authors.initials: DP
authors.lastname: Miller
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Carrozza
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Antman
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cannon
authors.forename: C Michael
authors.initials: CM
authors.lastname: Gibson
mesh_terms: D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy; D015425:Myocardial Reperfusion / Q000379:methods; D013997:Time Factors