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Door-to-needle, door-to-balloon times have decreased since 1990s

Wednesday, April 02 2008 | Comments
Evidence Grade 0 What's This?
By Nancy Stanley

Among patients with ST-segment elevation myocardial infarction (STEMI), in-hospital mortality has declined since the 1990s as a result of decreases in door-to-needle (DN) and door-to-balloon (DB) times, new data reveal.

To determine the trends in initial reperfusion strategy, DN times, DB times, and in-hospital mortality, researchers used data from approximately 1.4 million patients with STEMI who were enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. Of these patients, 65.9% were eligible for reperfusion upon arrival at the hospital, and 56.3% were eligible for time-to-reperfusion performance metrics.

Results showed that fibrinolytic therapy was the most prevalent reperfusion strategy used in 1990 among the reperfusion-eligible patients, defined as those with STEMI and a prehospital delay of <12 hours. However, the prevalence of using fibrinolytic therapy decreased from 52.5% in 1990 to 27.6% in 2006. During this same period, the use of primary percutaneous coronary intervention increased from 2.6% to 43.2%.

Among the patients treated with fibrinolytic therapy, median DN time decreased from 59 min in 1990 to 29 min in 2006 (P<.001 for trend). In addition, in-hospital mortality decreased significantly from 7.0% in 1994 to 6.0% in 2006 (P<.001 for trend).

Among all of the eligible patients, median DB time also decreased, from 120 min in 1994 to 87 min in 2006 (P<.001 for trend). Among the patients who were treated with primary percutaneous coronary intervention, median DB time for those who were not transferred from another hospital or emergency department (ED) decreased from 111 min to 79 min (P<.001 for trend), and for those who were transferred from another hospital or ED, median DB time decreased from 226 min to 139 min (P<.001 for trend).

This decrease in median DB time was accompanied by a "progressive decline" in in-hospital mortality for the patients treated with primary percutaneous coronary intervention (8.6% in 1994 vs 3.3% in 2006; P<.001 for trend). The decline in mortality between the transferred and the nontransferred patients was similar (8.7% to 3.9% vs 8.6% to 3.1%; P<.001 for both trends).

"The relative improvement in mortality attributable to improvements in DN times was estimated to be in the range of 14.3% to 16.3%, depending on whether changes in time to treatment were added to the model before or after other covariates," the authors wrote.

"Similarly, a range of 5.8% to 7.5% was estimated to be attributable to reductions in DB times," they added. (Gibson CM, et al. Poster 1024-52.)

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