title: Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute.
abstract: BACKGROUND
  Current guidelines for ST elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that in a real-world setting, median door-to-balloon (DTB) time is closer to 180 min for transfer patients, with less than 5% of patients being treated within 90 min. A retrospective observational study was conducted to assess time to treatment in patients undergoing primary PCI at the Quebec Heart and Lung Institute (QHLI).
  
  
  METHODS
  Consecutive lytic-eligible patients undergoing primary PCI at the QHLI for STEMI between April 2004 and March 2005 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes were in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared with those of patients presenting directly to the QHLI.
  
  
  RESULTS
  During the study period, 203 lytic-eligible patients were treated with primary PCI. Sixty-nine patients presented directly to the QHLI and 134 were transferred from other hospitals. Six transfer patients were excluded because of missing time variables. The median DTB time was 114 min in transfer patients, compared with 87 min in patients presenting directly to the QHLI (P<0.001). DTB time was less than 90 min in 24% of the transfer population compared with 55% of patients presenting directly to the QHLI (P<0.001). In patients referred from hospitals within a radius of 30 km from the QHLI (n=100), median DTB time was 106 min with 30% receiving PCI within 90 min. In these patients, estimated PCI-related delay was 74 min. For patients presenting to hospitals beyond 30 km (n=28), median DTB time was 142 min with 4% receiving reperfusion within 90 min. In these patients, estimated PCI-related delay was 110 min. Median DTB time for patients presenting during off hours at the QHLI was 92 min compared with 79 min for patients presenting during regular business hours (P=0.02). In patients transferred from other hospitals, median DTB time was 118 min during off hours and 108 min during normal business hours (P=0.07).
  
  
  CONCLUSIONS
  A DTB time of less than 90 min can be achieved in the majority of patients presenting directly to a primary PCI centre. However, for patients presenting to community hospitals, transfer for primary PCI is often associated with delayed revascularization. The present study highlights the need for careful patient selection when deciding between on-site thrombolytic therapy and transfer for primary PCI for STEMI patients presenting to hospitals without PCI facilities.
authors.affiliation: Quebec Heart and Lung Institute, Laval Hospital, Sainte Foy, Quebec City, Quebec.
authors.forename: Patrick
authors.initials: P
authors.lastname: Garceau
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Déry
authors.forename: Philippe
authors.initials: P
authors.lastname: Lachance
authors.forename: Stéfanie
authors.initials: S
authors.lastname: Grenier
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.forename: Gérald
authors.initials: G
authors.lastname: Barbeau
authors.forename: Olivier F
authors.initials: OF
authors.lastname: Bertrand
authors.forename: Onil
authors.initials: O
authors.lastname: Gleeton
authors.forename: Eric
authors.initials: E
authors.lastname: Larose
authors.forename: Can Man
authors.initials: CM
authors.lastname: Nguyen
authors.forename: Bernard
authors.initials: B
authors.lastname: Noël
authors.forename: Guy
authors.initials: G
authors.lastname: Proulx
authors.forename: Louis
authors.initials: L
authors.lastname: Roy
authors.forename: Robert
authors.initials: R
authors.lastname: de Larochellière
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D002309:Cardiology / Q000639:trends; D005260:Female; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006764:Hospitals, Community; D006801:Humans; D008297:Male; D008511:Medicine; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D010360:Patient Transfer; D011792:Quebec; D012189:Retrospective Studies; D013038:Specialization; D013997:Time Factors; D016896:Treatment Outcome