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J Am Coll Cardiol, 2006; 47:289-295, doi:10.1016/j.jacc.2005.08.065 (Published online 22 December 2005).
© 2006 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Door-to-Balloon Time With Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction Impacts Late Cardiac Mortality in High-Risk Patients and Patients Presenting Early After the Onset of Symptoms

Bruce R. Brodie, MD, FACC*,*, Charles Hansen, MA{dagger}, Thomas D. Stuckey, MD, FACC*, Scott Richter, PhD{ddagger}, Debra S. VerSteeg, RN*, Navin Gupta, MD, FACC*, William E. Downey, MD, FACC* and Mark Pulsipher, MD, FACC*

* LeBauer Cardiovascular Research Foundation and the Moses Cone Heart and Vascular Center, Greensboro, North Carolina
{dagger} Internal Medicine Residency Program, Moses H. Cone Memorial Hospital, Greensboro, North Carolina
{ddagger} Department of Mathematics, University of North Carolina at Greensboro, Greensboro, North Carolina

Manuscript received March 16, 2005; revised manuscript received August 9, 2005, accepted August 15, 2005.

* Reprint requests and correspondence: Dr. Bruce R. Brodie, 1126 North Church Street, Suite 300, Greensboro, North Carolina 27401. (Email: bbrodie{at}triad.rr.com).

OBJECTIVES: The purpose of this study was to evaluate the impact of door-to-balloon time with primary percutaneous coronary intervention (PCI) on late cardiac mortality.

BACKGROUND: The impact of door-to-balloon time on outcomes is controversial, and the impact on late mortality has not been studied.

METHODS: Consecutive patients (n = 2,322) treated with primary PCI from 1984 to 2003 were prospectively identified and followed up for a median of 83 months.

RESULTS: Prolonged door-to-balloon times (0 to 1.4 h vs. 1.5 to 1.9 h vs. 2.0 to 2.9 h vs. ≥3.0 h) were associated with higher in-hospital mortality (4.9% vs. 6.1% vs. 8.0% vs. 12.2%, p < 0.0001) and late mortality (12.6% vs. 16.4% vs. 20.4% vs. 27.1% at 7 years, p < 0.0001) and were an independent predictor of late mortality by Cox regression (p = 0.0004). Prolonged door-to-balloon times (≥2 h vs. <2 h) were associated with higher late mortality in high-risk patients (32.5% vs. 21.5%; hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.22 to 1.90; p = 0.0002) but not in low-risk patients (10.8% vs. 9.2%; HR, 1.13; 95% CI, 0.78 to 1.64; p = 0.53) and in patients presenting early (≤3 h) (24.7% vs. 15.0%; HR, 1.54; 95% CI, 1.24 to 1.90; p = 0.0001) but not late (>3 h) (21.1% vs. 18.5%; HR, 0.95; 95% CI, 0.62 to 1.45; p = 0.80).

CONCLUSIONS: Delays in door-to-balloon time impact late survival in high-risk but not low-risk patients and in patients presenting early but not late after the onset of symptoms. These findings have implications for the triage of patients for primary PCI.

Abbreviations and Acronyms
  CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications
  GUSTO = Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries
  NRMI = National Registry of Myocardial Infarction
  PAMI = Primary Angioplasty in Myocardial Infarction
  PCI = percutaneous coronary intervention
  STEMI = ST-segment elevation myocardial infarction
  TIMI = Thrombolysis In Myocardial Infarction




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