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Causes of delays in door-to-balloon time in PPCI patients

Tristan Manalac
28 Sep 2017

Unstable medical condition, atypical clinical presentation and delays in the emergency department are all contributing factors to delays in door-to-balloon (D2B) time in patients undergoing primary percutaneous coronary intervention (PPCI), a new study has found.

“Our registry showed that delay in D2B occurred in 16 percent of our patients undergoing PPCI for [ST-elevation myocardial infarction (STEMI)] but this did not translate into higher in-hospital mortality,” said researchers from the Tan Tock Seng Hospital in Singapore.

There were 1,268 PPCI patients (mean age 58.4±12.2 years; 86.4 percent male) included, of which 16 percent (n=202) experienced D2B delays while 84 percent (n=1,066) did not. The mean D2B times were 126±46 and 57±16 minutes in those who did and did not experienced delays, respectively, with the difference reaching significance (p<0.0001). [PLoS One 2017;doi:10.1371/journal.pone.0185186]

The overall rate of in-hospital mortality was 5.2 percent and, while the delay in D2B group had higher rates than the no delay group, the difference was not statistically significant (7.4 vs 4.8 percent, respectively; p=0.12).

The lack of association between in-hospital mortality and delay to D2B runs contrast to what has been mostly reported in the literature. However, a previous study has suggested that there may be a threshold limit to D2B time delays, beyond which no more significant impact on mortality can be observed. [Trial Circulation 1999;100:14-20; N Engl J Med 2013;369:901-909]

The most common cause of delays in D2B time was delays in the emergency department, which was reported by 39.1 percent (n=71) of the patients who experienced delays. This was followed by atypical clinical presentation (37.6 percent; n=76) and unstable medical condition that required stabilization and computed tomography imaging (26.7 percent; n=54).

Other reasons for delay in D2B time included difficult crossing culprit lesions (14.4 percent; n=29), difficult vascular access (9.4 percent; n=19) and issues with consent (4 percent; n=8). Reasons for delay that were marked as “unknown” in the medical records constituted 9 percent (n=18) of the total delay cases.

According to the researchers, delays in the emergency department may involve various operational issues including diagnosis and problems in triage.

“Formal training in the assessment of acute coronary syndrome to triage staff members in the ED could be provided regularly to improve their diagnostic acumen,” they said.

“Another potential solution is to perform an ECG for patients presenting with suspicious symptom anywhere from the neck to umbilical area,” they added.

Important future directions, the authors said, would be to identify other similar strategies that can prevent and further reduce D2B time delays, and implement them fully.

“With the advent of telemedicine and healthcare technology, we should embrace these advances and implement this key strategy in our PPCI programme in order to reduce D2B delay and hopefully achieve better clinical outcomes for our STEMI patients,” they said.

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