The recommended standard for best practices recommending a door to balloon time for ST Elevation Myocardial Infarction (STEMI) patients to be ≤ 90 minutes was established in the 2013 American College of Cardiology Foundation/American Heart Association Guidelines for STEMI. This has remained the accepted industry standard. But 2013 was a long time ago, and although programs continue to make this a metric that they strive to meet 100% of the time, there is not much discussion as to why we do this.
Of course, everyone in the industry recognizes that time is muscle and the quicker you re-establish flow in a blocked coronary artery, the better the outcome for the patient. But do we ever really think of the long-term effects of not meeting the standard? If we lose focus in the long-term, and only concentrate on the short-term, there is a danger of becoming lackadaisical in our expectations. More often than not when we do have a fallout, the artery is opened, blood-flow is re-established, and the patient does well. There is a sense that although the time exceeded 90 minutes, the patient was fine at the time of discharge, so everything worked out. But did it, really?
Studies have shown that an increase in door to balloon time has been linked to an increase in the length of stay, major adverse cardiac events, re-infarction, and short and long-term mortalities. In a study conducted from January 2013 through December 2021, it showed that for every 1 hour increase of door to balloon time, there is a 55% increase of 1 year mortality (Hsiao, Y.-T., Hung, J.-F., Zhang, S.-Q., Yeh, Y.-N., & Tsai, M.-J. (2023)). An increase in door-to-balloon time is proportionately related to a decrease in endothelial function, which in turn leads to an increase in the number of days a patient is in the hospital. The longer the door to balloon time, the larger the infarct, the more significant the decrease in LV (left ventricular function). LV dysfunction leads to diminished myocardial relaxation and LV stiffness, which is theorized to affect the diastolic heart function which in turn will affect the LV filling pressures and may contribute to new onset of heart failure.
In short, you may have re-established flow in the coronary artery, but there is a strong possibility due to the prolonged door to balloon time, you now have a patient who retains a level of heart failure that might have been avoided. This increases the possibility of major adverse cardiac events including mortality, increase in hospital costs and financial burden to the patient’s family, and decrease in quality of life.
Now that we’ve discussed the why, where do we go to ensure that we are meeting the goal of door-to-balloon times 100% of the time? It is essential that you have a strong quality program in place with a focus on the heart team approach to STEMI care. The success of a program depends solely on the concerted efforts and investment of the team from boots on the ground to upper management. All members, from EMS, the Emergency Department, the Cardiac Cath Lab and ancillary departments (Echo Lab, EP, etc.), post care areas, and leadership must take active responsibility for the achievement of this goal. There must be a continuous assessment of the path of a STEMI from activation to recovery that includes patient follow-up after discharge.
Where does the path of a STEMI begin? It begins with recognition and activation. It begins with EMS, the emergency room registration for walk-in patients, and the emergency department. Early recognition is key to consistently meeting your door to balloon times. Once a STEMI is identified, everything should fall into place like dominoes. But this cannot happen until the STEMI is identified. If the STEMI is not identified within 10 minutes or less from hitting the emergency room door, there is a high likelihood that you will not meet the door to balloon time. If the emergency room is not identifying the STEMI efficiently, then the rest of the team is forced to try to make up the difference and is set up to fail. The door to EKG time is not only crucial to the success of a STEMI program, but also the determining factor to success. And it is so easy to meet the door to EKG time in less than 10 minutes consistently. All it takes is education, diligence, determination, and most of all, effective communication. Success may be as simple as tracking timelines and requiring signatures at every step in the process from patient arrival to a physician reading the EKG and making the determinant diagnosis. There must be a level of accountability.
If you are struggling to meet these two crucial criteria, door to balloon and door to EKG, you may need to further develop your quality program. There are many ways in which you can do that. If you find this to be challenging, Corazon offers Cath/PCI Accreditation, Chest Pain Accreditation, and program assessments, analysis, or GAP studies to help you identify your needs so that you may achieve your goals of meeting your time goals 100%. In turn, you will be saving more lives and making the lives you do save that much better.
References:
Hsiao, Y.-T., Hung, J.-F., Zhang, S.-Q., Yeh, Y.-N., & Tsai, M.-J. (2023). The impact of emergency department arrival time on door-to-balloon time in patients with st-segment elevation myocardial infarction receiving primary percutaneous coronary intervention. Journal of Clinical Medicine, 12(6), 2392. https://doi.org/10.3390/jcm12062392
Kumar, V. (n.d.). Influence of 20-Year Reduction in Door-to-Balloon Times on Outcomes of Patients with Anterior St-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Prospective Cohort Study. https://doi.org/10.51168/sjhrafrica.v5i3.1028
Park, J., Choi, K. H., Lee, J. M., Kim, H. K., Hwang, D., Rhee, T., Kim, J., Park, T. K., Yang, J. H., Song, Y. B., Choi, J., Hahn, J., Choi, S., Koo, B., Chae, S. C., Cho, M. C., Kim, C. J., Kim, J. H., Jeong, M. H., … Kim, H. (2019). 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. Journal of the American Heart Association, 8(9). https://doi.org/10.1161/jaha.119.012188
Vahldieck, C., Fels, B., Löning, S., Nickel, L., Weil, J., & Kusche-Vihrog, K. (2023). Prolonged door-to-balloon time leads to endothelial glycocalyx damage and endothelial dysfunction in patients with st-elevation myocardial infarction. Biomedicines, 11(11), 2924. https://doi.org/10.3390/biomedicines11112924
