Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program.
BACKGROUND
The speed of reperfusion (door-to-balloon [D2B] time) is a well established performance metric for patients with ST-elevation myocardial infarction. Although preferably D2B times should be <or=90 minutes, it is unclear how consistently this is achieved in community practice, particularly in women, elderly people, and minorities.


METHODS
We used the American Heart Association Get With the Guidelines database to study D2B times at 254 participating United States sites (2002-2006). Median D2B time and percentage of compliance with goal (percutaneous coronary interventions [PCI] <or=90 minutes) were assessed overall, over time, and among patient subgroups associated with the greatest delay in this time (older patients, women, and minorities). Standard generalized estimating equation was used to assess continuous trend, percentage of compliance (PCI <or=90 minutes) over time, and disparities in care based on race, sex, and age.


RESULTS
Over the study period, 10965 patients with ST-elevation myocardial infarction who met eligibility criteria received primary PCI (36% aged >or=65 years, 27% female, and 17% nonwhite). The overall median D2B time was 96 minutes (interquartile range [IQR] 69-140 minutes). Only 44.8% of cases had D2B <or=90 minutes. Median D2B time improved over the study period (108 minutes at baseline [fourth quarter of 2002] to 82 minutes by the last study quarter [third quarter of 2006], adjusted P = .001). The percentage achieving D2B <or=90 minutes also improved (36.2%-58.8%, adjusted P = .003). Relative to their peers, patients aged >or=65 years (103 [IQR 74-153] vs 93 [IQR 67-133] minutes), women (103 [IQR 73-154] vs 94 [IQR 68-135] minutes), and minorities (108 [IQR 77-162] vs 95 [IQR 68-136] minutes) had significantly longer median D2B times. These subgroup disparities in the D2B persisted over the study period as compared with their peers.


CONCLUSIONS
The median D2B times with primary PCI have improved modestly in hospitals participating in the American Heart Association Get With the Guidelines program over the last few years but remain below ideal levels. The D2B times are particularly delayed in the elderly people, women, and minority populations; an issue that has persisted over time. These results highlight the ongoing need for national myocardial infarction quality improvement initiatives.
Mehta
Rajendra H
RH
Duke Clinical Research Institute and Duke University Medical Center, Durham, NC, USA.
Bufalino
Vincent J
VJ
Pan
Wenqin
W
Hernandez
Adrian F
AF
Cannon
Christopher P
CP
Fonarow
Gregg C
GC
Peterson
Eric D
ED
D000367:Age Factors; D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D004562:Electrocardiography; D005260:Female; D019983:Guideline Adherence; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D008913:Minority Groups; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion; D017064:Process Assessment, Health Care; D012737:Sex Factors; D013997:Time Factors