Key result
A door-to-balloon delay of >90 minutes was associated with a significantly increased risk of 30-day mortality (RR 1.58) compared to a delay of ≤90 minutes in patients with STEMI.
Why the study?
Existing literature on the door-to-balloon time-outcome relationship in coronary intervention is limited by the potential for residual biases from unobserved confounders.
Does a door-to-balloon delay of >90 minutes increase mortality and adverse outcomes in adults with STEMI undergoing primary PCI?
Cohort (n=4,343)
Yes
Does a door-to-balloon delay of >90 minutes increase mortality and adverse outcomes in adults with STEMI undergoing primary PCI?
Longer door-to-balloon delay (>90 minutes) is consistently associated with a higher risk of adverse outcomes, including mortality, at the population level, even after adjusting for observed and unobserved confounders.
Shorter door-to-balloon time remains prognostic after unobserved confounder adjustment; leaves open whether further reductions improve outcomes in contemporary STEMI care.
Literature studying the door-to-balloon time-outcome relation in coronary intervention is limited by the potential of residual biases from unobserved confounders. This study re-examines the time-outcome relation with further consideration of the unobserved factors and reports the population average effect. Adults with ST-elevation myocardial infarction admitted to one of the six registry participating hospitals in Australia were included in this study. The exposure variable was patient-level door-to-balloon time. Primary outcomes assessed included in-hospital and 30 days mortality. 4343 patients fulfilled the study criteria. 38.0% (1651) experienced a door-to-balloon delay of >90 minutes. The absolute risk differences for in-hospital and 30-day deaths between the two exposure subgroups with balanced covariates were 2.81 (95% CI 1.04, 4.58) and 3.37 (95% CI 1.49, 5.26) per 100 population. When unmeasured factors were taken into consideration, the risk difference were 20.7 (95% CI -2.6, 44.0) and 22.6 (95% CI -1.7, 47.0) per 100 population. Despite further adjustment of the observed and unobserved factors, this study suggests a directionally consistent linkage between longer door-to-balloon delay and higher risk of adverse outcomes at the population level. Greater uncertainties were observed when unmeasured factors were taken into consideration.
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Foo et al. (2019) conducted a cohort in ST-elevation myocardial infarction (n=4,343). Door-to-balloon delay >90 minutes vs. Door-to-balloon time ≤90 minutes was evaluated on 30-day mortality (RR 1.58, 95% CI 1.21, 1.95, p=<0.001). A door-to-balloon delay of >90 minutes was associated with a significantly increased risk of 30-day mortality (RR 1.58) compared to a delay of ≤90 minutes in patients with STEMI.
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