title: Door-to-balloon time in primary percutaneous coronary intervention predicts degree of myocardial necrosis as measured using cardiac biomarkers.
abstract: Reduced door-to-balloon time in primary percutaneous coronary intervention for the treatment of ST-elevation myocardial infarction has been associated with lower cardiac mortality rates. However, it remains unclear whether door-to-balloon time is predominantly a surrogate for overall peri-myocardial infarction care and is not independently predictive of outcomes, particularly when differences in door-to-balloon time have narrowed and previous studies have contained myocardial infarction-selection bias.We analyzed 179 consecutive patients who presented emergently at our cardiac catheterization laboratory with ST-elevation myocardial infarction within 12 hours of symptom onset and who underwent primary percutaneous coronary intervention within 3 hours of presentation. Our curve estimation regression model used the natural logarithm (ln) of area under the curve (AUC) of creatine kinase to evaluate the effect of door-to-balloon time on cardiac biomarker levels. We correlated ln (AUC-creatine kinase) with improvement of left ventricular ejection fraction at follow-up and with the intermediate-term mortality rate.Median door-to-balloon time was 87 minutes (interquartile range, 65-113 min). The ln (AUC-creatine kinase) correlated significantly with door-to-balloon time (r=0.2, P=0.02). Upon propensity-score analysis, door-to-balloon time remained a significant independent predictor of ln (AUC-creatine kinase) (beta=0.15, P=0.03). Upon use of a Cox regression model, ln (AUC-creatine kinase) independently predicted death (P=0.04) and recovery of left ventricular function (P=0.001) at follow-up (mean, 14 mo).Longer door-to-balloon time independently predicts increased myocardial cell damage, and ln (AUC-creatine kinase) predicts improvement in left ventricular systolic function and intermediate-term death after ST-elevation myocardial infarction.
authors.affiliation: Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York 10065, USA. RMM2002@med.cornell.edu
authors.forename: Robert M
authors.initials: RM
authors.lastname: Minutello
authors.forename: Luke
authors.initials: L
authors.lastname: Kim
authors.forename: Smita
authors.initials: S
authors.lastname: Aggarwal
authors.forename: Linda J
authors.initials: LJ
authors.lastname: Cuomo
authors.forename: Dmitriy N
authors.initials: DN
authors.lastname: Feldman
authors.forename: S Chiu
authors.initials: SC
authors.lastname: Wong
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality; D019540:Area Under Curve; D015415:Biomarkers / Q000097:blood; D003402:Creatine Kinase / Q000097:blood*; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology / Q000503:physiopathology; D009206:Myocardium / Q000201:enzymology* / Q000473:pathology; D009336:Necrosis; D057216:Propensity Score; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D020127:Recovery of Function; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left
chemical_list: D015415:Biomarkers; D003402:Creatine Kinase
references.citation: N Engl J Med. 2006 Nov 30;355(22):2308-20
references.pmid: 17101617
references.citation: J Am Coll Cardiol. 2006 Jun 6;47(11):2180-6
references.pmid: 16750682
references.citation: JAMA. 2000 Jun 14;283(22):2941-7
references.pmid: 10865271
references.citation: Am J Cardiol. 2007 Nov 1;100(9):1370-5
references.pmid: 17950792
references.citation: Heart. 2007 Dec;93(12):1552-5
references.pmid: 17591643
references.citation: Am Heart J. 2006 Jun;151(6):1231-8
references.pmid: 16781224
references.citation: Am J Cardiol. 2004 Sep 15;94(6):772-4
references.pmid: 15374785
references.citation: Circulation. 2004 Mar 16;109(10):1223-5
references.pmid: 15007008
references.citation: J Am Coll Cardiol. 2003 Sep 17;42(6):991-7
references.pmid: 13678918
references.citation: Circulation. 2006 Jan 17;113(2):222-9
references.pmid: 16401769
references.citation: Curr Control Trials Cardiovasc Med. 2005 Aug 23;6:12
references.pmid: 16115321
references.citation: Am Heart J. 2003 Apr;145(4):708-15
references.pmid: 12679769
references.citation: N Engl J Med. 2008 Jan 17;358(3):231-40
references.pmid: 18199862
references.citation: Circulation. 1999 Jul 6;100(1):14-20
references.pmid: 10393675
references.citation: Am J Cardiol. 2002 Jun 1;89(11):1248-52
references.pmid: 12031722
references.citation: J Am Coll Cardiol. 2008 Jan 15;51(2):210-47
references.pmid: 18191746
references.citation: Heart. 2005 Aug;91(8):1041-6
references.pmid: 16020592
references.citation: Circulation. 2005 Feb 15;111(6):761-7
references.pmid: 15699253
references.citation: J Am Coll Cardiol. 2006 Jan 17;47(2):289-95
references.pmid: 16412849
references.citation: JAMA. 2005 Aug 17;294(7):803-12
references.pmid: 16106005
references.citation: Am J Cardiol. 2003 Oct 1;92(7):824-6
references.pmid: 14516884
references.citation: Circulation. 2008 May 13;117(19):2502-9
references.pmid: 18427127
references.citation: Eur Heart J. 2006 Apr;27(7):779-88
references.pmid: 16513663
references.citation: Circulation. 2006 Nov 7;114(19):2019-25
references.pmid: 17075010
references.citation: Eur Heart J. 2002 Apr;23(7):550-7
references.pmid: 11922645