For more than a decade, efforts to improve door-to-balloon (D2B) times for STEMI patients have led to new support systems and guideline recommendations that have, in turn, expedited care from the moment patients arrive at the hospital. But as those practices have become more routine and nuanced, experts are taking a good hard look at what happens to patients before they get to the hospital and in particular at whether a shift in focus to “first medical contact”-to-balloon times has made any meaningful gains.
“We’re clearly a lot better than we were 10 years ago, but the reality is we’re probably not as good as we think,” Timothy Henry, MD (Cedars-Sinai Heart Institute, Los Angeles, CA), told TCTMD. “Everybody thinks that this issue is solved, but it’s not.”
In 2004, American College of Cardiology (ACC) guidelines stated that primary PCI should be performed within 90 minutes. At the time, a goal of less than 90 minutes was thought by many to be impossible for the nation, even as both the ACC and the American Heart Association launched national campaigns (D2B Alliance and Mission: Lifeline) to promote improvement in door-to-balloon times nationwide.
Those initiatives are paying off. As reported in a national assessment of D2B times, the intensive efforts coupled with the Centers for Medicare & Medicaid Services’ Hospital Compare program were credited with contributing to a marked increase—from 44.2% to 91.4%—in the proportion of patients with D2B times below 90 minutes over the 6-year period beginning in 2005.
Then in 2013, a full-scale revision of the guidelines for STEMI management proposed that the D2B benchmark be changed to first medical contact (FMC)-to-device time, which would include any prehospital location and virtually any type of device (balloons, coronary stents, wires, aspiration catheters, etc). This shift put the emphasis on early assessment, care, and transport, and recommended a time of 90 minutes or less.
“As we’ve gotten our house in order with regard to door-to-balloon time, it’s allowed us to think a bit more preemptively about how we can better coordinate with prehospital systems,” noted Brahmajee Nallamothu, MD (University of Michigan, Ann Arbor).