Volume 185 - Issue 9
Guidelines for the management of acute coronary syndromes 2006
Author: Jayantha I Weeraratne
Med J Aust 2006; 185 (9): 526-527. || doi: 10.5694/j.1326-5377.2006.tb00674.x
Published online: 6 November 2006
Published online: 6 November 2006
To the Editor: The recommendation for managing acute ST-segment-elevation myocardial infarction with percutaneous coronary intervention (PCI) is that the door-to-balloon inflation time should be 90 minutes. However, it can be up to 120 minutes, depending on when patients present to the emergency department (ED) after the onset of their symptoms.1 In such cases, an alternative immediate reperfusion strategy — fibrinolysis — should be considered.
At first glance, a door-to-balloon time of 90 minutes seems readily achievable, but what if the patient presents after hours, or presents to a hospital without PCI facilities?
The time required to refer the patient for PCI, organise ambulance transport and call in cardiac catheterisation laboratory staff can be considerable.
In the PRAGUE-2 trial from the Czech Republic, the average door-to-balloon time was 97 minutes.2 The DANAMI-2 study from Denmark had a cohort of 27 080 patients and had door-to-balloon times of about 114 minutes for those patients transferred to another facility.3 The National Registry of Myocardial Infarction 4 investigators reported a median door-to-balloon time of 185 minutes for American patients transferred to centres capable of PCI, and a door-to-balloon time of less than 90 minutes for only 3% of patients.4
Doctors working in EDs without onsite access to PCI need to know the door-to-balloon times of the institutions to which they refer patients for PCI. Centres performing PCI may not be forthcoming with this information, as they have a vested interest in keeping their numbers up for PCI. Alternatively, this information may not be known to the clinician accepting the patient for PCI.
In addition, doctors in EDs who opt to transfer their patients have the burden of organising transport for potentially unstable patients who may develop lethal arrythmias.
As door-to-needle time for thrombolysis has become a clinical indicator for EDs, perhaps door-to-balloon times can be a clinical indicator for cardiac catheterisation laboratories.
Finally, it is important to note that in some patients requiring urgent coronary artery reperfusion, the first electrocardiogram (ECG) is not diagnostic, so a more pragmatic indicator would be diagnostic ECG-to-balloon time. This would require an enforcement of the current recommendations for an ECG to be performed and critically reviewed shortly after a patient presents with symptoms suggestive of an acute coronary syndrome.
References
- Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 (8 Suppl): S1-S32.
- Widimsky P, Budesinsky T, Vorac D, et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction: final results of the randomized national multicentre trial — PRAGUE-2. Eur Heart J 2003; 24: 94-104. 0_i1091788
- Anderson HR, Neilsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003; 349: 733-742. 0_i1091792
- NRMI 4 Investigators. The National Registry of Myocardial Infarction 4 quarterly data report. South San Francisco, Calif: Genentech, March 2003. 0_i1091793