Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min. To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI. We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017. Median DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011). A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times. Está recomendado que os doentes com enfarte agudo do miocárdio com supra de ST (EAMcSST) que necessitam de transferência inter-hospitalar para a intervenção coronária percutânea primária (ICPP) tenham um tempo de door in-door out (DIDO) ≤30 minutos. Avaliar o tempo DIDO dos hospitais que transferem pacientes com EAMcSST para ICP e o seu impacto no tempo total de isquemia e outcomes clínicos. Estudo retrospetivo com 523 doentes com EAMcSST transferidos para a ICPP, entre 1 de janeiro de 2013 e 30 de junho de 2017. A mediana do tempo DIDO foi de 82 minutos (intervalo interquartílico [IQ], 61-132 minutos). Apenas 7 pacientes (1,3%) foram transferidos em ≤30 minutos. Os pacientes com um tempo DIDO >60 minutos apresentavam atrasos de sistema (207,3 min versus 112,7 min; p<0,001) e tempos totais de isquemia (344,2 min versus 222 min; p<0,001) significativamente superiores quando comparados com os doentes que eram transferidos em ≤60 minutos. A mortalidade intra-hospitalar foi significativamente superior nos pacientes com tempo DIDO >60 minutos (5,1% versus 0%; p=0,006; odds ratio ajustada para a mortalidade intra-hospitalar, 1,27 [95% IC, 1,062-1,432]). Até à data de follow-up, os doentes pertencentes ao grupo “>60 min” apresentavam uma maior proporção de eventos de morte, p=0,016 e o tempo de sobrevivência era significativamente inferior, p=0,011. O tempo DIDO ≤30 minutos foi observado numa pequena proporção de doentes. DIDO ≤60 minutos associaram-se a menores atrasos na reperfusão, a menor mortalidade intra-hospitalar e a maiores tempos de sobrevivência.