Prognostic Implications of Door-to-Balloon Time and Onset-to-Door Time on Mortality in Patients With ST -Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Abstract

Background In patients with ST-segment-elevation myocardial infarction, timely reperfusion therapy with door-to-balloon (D2B) time <90 minutes is recommended by the current guidelines. However, whether further shortening of symptom onset-to-door (O2D) time or D2B time would enhance survival of patients with ST-segment-elevation myocardial infarction remains unclear. Therefore, the current study aimed to evaluate the prognostic impact of O2D or D2B time in patients with ST-segment-elevation myocardial infarction who underwent primary percutaneous coronary intervention. Methods and Results We analyzed 5243 patients with ST-segment-elevation myocardial infarction were treated at 20 tertiary hospitals capable of primary percutaneous coronary intervention in Korea. The association between O2D or D2B time with all-cause mortality at 1 year was evaluated. The median O2D time was 2.0 hours, and the median D2B time was 59 minutes. A total of 92.2% of the total population showed D2B time ≤90 minutes. In univariable analysis, 1-hour delay of D2B time was associated with a 55% increased 1-year mortality, whereas 1-hour delay of O2D time was associated with a 4% increased 1-year mortality. In multivariable analysis, D2B time showed an independent association with mortality (adjusted hazard ratio, 1.90; 95% CI , 1.51-2.39; P<0.001). Reducing D2B time within 45 minutes showed further decreased risk of mortality compared with D2B time >90 minutes (adjusted hazard ratio, 0.30; 95% CI , 0.19-0.42; P<0.001). Every reduction of D2B time by 30 minutes showed continuous reduction of 1-year mortality (90 to 60 minutes: absolute risk reduction, 2.4%; number needed to treat, 41.9; 60 to 30 minutes: absolute risk reduction, 2.0%; number needed to treat, 49.2). Conclusions Shortening D2B time was significantly associated with survival benefit, and the survival benefit of shortening D2B time was consistently observed, even <60 to 90 minutes.

Keywords: acute myocardial infarction; door‐to‐balloon time; outcome; percutaneous coronary intervention; prognosis.

Figure 1

Distribution of symptom onset‐to‐door (A) and door‐to‐balloon (B) times of the study population.

Figure 2

One‐year mortality, according to symptom onset‐to‐door (O2D) and door‐to‐balloon (D2B) times. A, The rate of crude 1‐year all‐cause mortality was compared among classification of D2B time (x axis) in strata of O2D time (blue lines, left) or was compared among classification of O2D time (x axis) in strata of D2B time (red lines, right). B, Multivariable adjusted all‐cause mortality at 1 year was compared among classification of D2B time (x axis) in strata of O2D time (blue lines, left) or was compared among classification of O2D time (x axis) in strata of D2B time (red lines, right). n.s. Indicates not significant.

Figure 3

Comparison of clinical outcome, according to door‐to‐balloon (D2B) time. Comparison of all‐cause mortality at 1 year among classifications by D2B time.

Figure 4

Association between door‐to‐balloon (D2B) time and 1‐year mortality. The association between relative all‐cause mortality rates and D2B time is presented among the total study population (A) and patients whose D2B time was within 120 minutes (B). In both populations, the continuous association between shorter D2B time and lower relative risk of 1‐year mortality was consistently observed. The association between D2B time and the 1‐year mortality was plotted under multivariable adjustment.