title: When is door-to-balloon time critical? Analysis from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trials.
abstract: OBJECTIVE
  Our objective was to evaluate the impact of door-to-balloon time (DBT) on mortality depending on clinical risk and time to presentation.
  
  
  BACKGROUND
  DBT affects the mortality rate in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, but the impact may vary across subgroups.
  
  
  METHODS
  The CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials evaluated stent and antithrombotic therapy in patients undergoing primary percutaneous coronary intervention. We studied the impact of DBT on mortality in 4,548 patients based on time to presentation and clinical risk.
  
  
  RESULTS
  The 1-year mortality rate was lower in patients with short versus long DBT (< or = 90 min vs. >90 min, 3.1% vs. 4.3%, p = 0.045). Short DBTs were associated with a lower mortality rate in patients with early presentation (< or = 90 min: 1.9% vs. 3.8%, p = 0.029) but not those with later presentation (>90 min: 4.0% vs. 4.6%, p = 0.47). Short DBTs showed similar trends for a lower mortality rate in high-risk (5.7% vs. 7.4%, p = 0.12) and low-risk (1.1% vs. 1.6%, p = 0.25) patients. Short DBTs had similar relative risk reductions in patients with early presentation in high-risk (3.7% vs. 7.0%, p = 0.08) and low-risk (0.8% vs. 1.5%, p = 0.32) patients, although the absolute benefit was greatest in high-risk patients.
  
  
  CONCLUSIONS
  Short DBTs (< or = 90 min) are associated with a lower mortality rate in patients with early presentation but have less impact on the mortality rate in patients presenting later. The absolute mortality rate reduction with short DBT is greatest in high-risk patients presenting early. These data may be helpful in designing triage strategies for reperfusion therapy in patients presenting to non-percutaneous coronary intervention hospitals.
authors.affiliation: LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina, USA.bbrodie@triad.rr.com
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Brodie
authors.forename: Bernard J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: Thomas
authors.initials: T
authors.lastname: Stuckey
authors.forename: Bernhard
authors.initials: B
authors.lastname: Witzenbichler
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
authors.forename: Jan Z
authors.initials: JZ
authors.lastname: Peruga
authors.forename: Dariusz
authors.initials: D
authors.lastname: Dudek
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Grines
authors.forename: David
authors.initials: D
authors.lastname: Cox
authors.forename: Helen
authors.initials: H
authors.lastname: Parise
authors.forename: Abhiram
authors.initials: A
authors.lastname: Prasad
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D000077284:Abciximab; D000368:Aged; D017130:Angioplasty / Q000379:methods*; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D000911:Antibodies, Monoclonal / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use; D002309:Cardiology / Q000379:methods; D005260:Female; D006353:Heart-Assist Devices; D006760:Hospitalization; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D009204:Myocardial Revascularization; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000911:Antibodies, Monoclonal; D000925:Anticoagulants; D007140:Immunoglobulin Fab Fragments; D000077284:Abciximab