title: Nonsystem reasons for delay in door-to-balloon time and associated in-hospital mortality: a report from the National Cardiovascular Data Registry.
abstract: OBJECTIVE
  The goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the impact on in-hospital mortality.
  
  
  BACKGROUND
  Studies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.
  
  
  METHODS
  We analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the CathPCI Registry from January 1, 2009, to June 30, 2011.
  
  
  RESULTS
  Nonsystem delays occurred in 14.7% of patients (n = 12,146). Patients with nonsystem delays were more likely to be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without delay was 2.5% versus 15.1% for those with delay (p < 0.01). Nonsystem delay reasons included delays in providing consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), "other" (31%), and cardiac arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to 75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p < 0.0001). After adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.
  
  
  CONCLUSIONS
  Nonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary percutaneous coronary intervention are common and associated with high in-hospital mortality.
authors.affiliation: New York Presbyterian Hospital, Weill Cornell Medical College, Greenberg Division of Cardiology, New York, New York, USA. rvs9001@med.cornell.edu
authors.forename: Rajesh V
authors.initials: RV
authors.lastname: Swaminathan
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Kaltenbach
authors.forename: Luke K
authors.initials: LK
authors.lastname: Kim
authors.forename: Robert M
authors.initials: RM
authors.lastname: Minutello
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Bergman
authors.forename: S Chiu
authors.initials: SC
authors.lastname: Wong
authors.forename: Dmitriy N
authors.initials: DN
authors.lastname: Feldman
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality*; D017023:Coronary Angiography; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors