Research Paper: Door to Balloon Time

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[. . .] These patients should not be evaluated over the telephone. The preferable mode of transport to the emergency department should be via an EMS rather than with private transport. (Harding et al., 2010)

In order to minimize the delay, patients are advised not to repeat a second dose of nitroglycerine if the pain persists. (Harding et al., 2010) Instead, an EMS should be contacted immediately and an additional two doses, at fifteen minute intervals, can be taken while waiting for EMS arrival. Current protocols also advocate the use of a pre-hospital ECG in order to distinguish STEMI patients for immediate transfer to PCI facilities. (Harding et al., 2010) For patients who do not have ST segment or T. wave changes, a repeat ECG after twenty minutes is advised. Serial ECGs in the emergency department are also recommended for evolutionary changes that are not initially apparent.

These guidelines also provide insight to the dilemma of whether to transfer high risk PCI candidates to PCI centers from non-PCI centers. The new Class 11 recommendation is that it is reasonable for such high risk PCI candidates, who have received fibrinolytic therapy, to be immediately transferred to PCI receiving centers from PCI referral centers. (Preeti, 2011) PCI will then be performed as needed or as a pharmaco-invasive strategy. These recommendations also favor initiating a preparatory anti-thrombotic regimen before and during transfer to a PCI facility. (Preeti, 2011)


To analyze the effect of pre-hospital management of ST-segment elevation myocardial infarction on door to balloon times and long-term patient mortality.

Method and Material:

A systematic review was performed on the relevant literature available regarding the role of pre-hospital management on the outcome of STEMI patients. First, a thorough read was given to the subsequent changes in the protocols from the year 2007 and onwards regarding STEMI management.

A list of factors affecting pre-hospital delay was first identified. These factors included: time of onset of symptoms to EMS call, time from call to EMS arrival, transport time, time delay at the Emergency department and activation of concerned team and finally time taken during transfer of patients to PCI lab to the inflation of balloon.

The meta-analysis of observational studies in epidemiology group, MOOSE, guidelines was used to assist the review. (Stroup et al., 2008) A total of fifty articles were identified using the PUBMED, GOOGLE SCHOLARS and UPTODATE database. Keywords used to assist the search included, "Pre-hospital management," "Pre-hospital triage," "STEMI," "EMS vs. Private transport," "role of 12 lead ECG," "Pre-hospital protocol" and "Bypass of non-PCI centers."

All articles that discussed pre-hospital management of STEMI and factors affecting it were included in the systemic review. Also, studies were included only if they reported data on adults (> 18 years) who were diagnosed with acute STEMI, experienced chest pain for less than 12 hours and were identified by EMS personnel in the pre-hospital environment. Articles that compared EMS service to private transport were also used. A few studies analyzed the effectiveness of certain protocols for pre-hospital management of STEMI and were also considered. Articles that were published after the year 2009 were preferred. Studies conducted from each continent were included in the analysis.

A quality appraisal tool was used to evaluate the credibility, rigor and relevance of each study. (Public Health Resource Unit, 2006) After a thorough read of each article, the title, author names and institutional affiliations were blinded to the author and the sequence was jumbled. All citations of each article were reviewed independently in a hierarchical manner. The quality appraisal tool was then used to evaluate relevance, credibility and rigor. Each article was then classified under either "INCLUDE" or "DISCARD." A total of thirty studies were chosen in this manner.

The time duration, target population, number of subjects per article, study method and any other consideration for each article was then summarized. A summary of this is provided below. Each of the factors studied in each research were then identified and its effect on door to balloon time and 30 day mortality was calculated and evaluated on tables and figures using Microsoft Excel.

Factors predicted to affect D2B, D2N and overall mortality of STEMI patients were: use of 12 lead ECG in a pre-hospital setting, EMS verses Private transport of patients, patients presenting to the ED during off-hours, bypass of non-PCI centers for patients with confirmed STEMI and activation of PCI labs and concerned teams by the EMS.

Most studies divided the D2B time into: Decision to seek care using private vs. EMS; Decision to seek care -- hospital arrival; Decision to seek care -- reperfusion therapy; Symptoms -- reperfusion therapy. The eligibility criteria for patients undergoing primary PCI were: symptom duration of 12 hours or less and ST-segment elevation of 0.1 mV or greater in at least 2 contiguous leads (0.2mV in V1-V3) or presumed new-onset left bundle-branch block.

Out of a total of thirty published studies that were used for this systemic review, eighteen articles and two meta-analyses were identified to have analyzed the effect of pre-hospital triage on door to balloon time, door to needle time and over-all mortality of STEMI patients. A sum of 14327 patients met the inclusion criteria. The sample was a good representative of populations from the United States, Australia, Qeubec, New Zealand, Canada, Switzerland, Amsterdam, Lebanon and Denmark. Seven out of the eighteen researches were conducted using a data base for national records and contributed to a comparatively greater sample size. These researches represented the following locations: Western Denmark, Netherland, the United States and Quebec. Most of the articles identified were pre and post interventional designs based on a single hospital.

A great majority of studies evaluated the effectiveness of a pre-hospital triage. The pre-hospital triage advocates the use of a pre-hospital ECG, thus allowing activation of PCI labs prior to patient arrival and direct transport of confirmed STEMI patients to PCI facilities. These articles analyzed the effect of bypassing non-interventional facilities and the emergency department through pre-hospital ECG and its interpretation by paramedics or its transmission to the on-call emergency team. The efficacy of transmission was also analyzed by one study that was conducted in Australia.

A meta-analysis study of 2264 citations identified 980 patients that were directly transferred to a PCI lab (Brooks et al., 2009). Ten other studies and one meta-analysis that were conducted on the usefulness of pre-hospital triage were used to formulate results and draw a conclusion.

One study, conducted in a rural set up, investigated the efficacy of thrombolytic treatment prior to transport to PCI facilities (Crowder et al., 2011). A similar research, conducted on transfer of STEMI patient, evaluated the practicality of transfer of patients from non-PCI to PCI facilities.

A separate study was conducted to evaluate the usefulness of 'Code STEMI' in reducing the D2B time (Bajaj et al., 2011). The Code STEMI was established to produce better results for STEMI patients who presented in "off hours." Off hours were described to be weekday nights, weekends and official holidays. In this study, patients were divided into two groups. The first group consisted of 27 STEMI patients that presented to the hospital during off hours before the Code STEMI was operational (January -- December 2006). The second group included 60 patients who presented to the hospital during off hours when Code STEMI was fully functional. (January 2007 -- December 2008) A similar study identified the usefulness of a STEMI care system from January 2008 to December 2010. This was a prospective observational study that included a pre-hospital ECG by paramedics.

One study evaluated the effectiveness of ECG transmission from ambulances using computerized Glasgow algorithm to two cardiologists as part of the pre-hospital triage. The efficacy of transmission, sensitivity and specificity of interpretation was calculated. Two similar studies evaluated transmission time as part of pre-hospital delay.

Out of the eighteen studies conducted, six analyzed the popularity of EMS amongst the general population. The quickness of EMS was also compared to Private transport. A total of 15541 STEMI patients were identified that presented to the ED through either EMS or Private transport. The studies that were chosen in this meta- analysis were from different parts of the world, namely, The United States, Canada, the Gulf countries, Sweden and China.

One study that was conducted in Ottawa from July 2001 to January 2004 used the Ottawa Hospital STEMI registry to prospectively collect results on all STEMI patients (So et al., 2006). This study analyzed the use of EMS (as compared to Private transport) and its relationship to treatment, morbidity and mortality of STEMI patients.

A study was conducted using data from the Rapid Early Action for Coronary Treatment Trial (REACT- Trial). This trial used data from 20 different cities in the United States (Aghari et al., 2011). Elapsed travel times were ranked within Zip Codes and submitted to a nested analysis of variance model to determine if elapsed time was different for the different modes of transport.

A similar prospective, observational study was conducted to determine the time for an… [END OF PREVIEW]

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Cite This Research Paper:

APA Format

Door to Balloon Time.  (2012, March 27).  Retrieved July 22, 2019, from

MLA Format

"Door to Balloon Time."  27 March 2012.  Web.  22 July 2019. <>.

Chicago Format

"Door to Balloon Time."  March 27, 2012.  Accessed July 22, 2019.