Archive for September, 2014

Journal Club 3 September 2014


Nonsystem Reasons for Delay in Door-to-Balloon Time and Associated In-Hospital Mortality
A Report From the National Cardiovascular Data Registry


SH (paper chosen by RS)



The goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the
impact on in-hospital mortality.


Studies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic
characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.


We analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction
patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the Cath-
PCI Registry from January 1, 2009, to June 30, 2011.


Nonsystem delays occurred in 14.7% of patients (n 12,146). Patients with nonsystem delays were more likely to
be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without
delay was 2.5% versus 15.1% for those with delay (p 0.01). Nonsystem delay reasons included delays in providing
consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), “other” (31%), and cardiac
arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the
shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had
a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to
75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and
other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p 0.0001). After
adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.


Nonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary
percutaneous coronary intervention are common and associated with high in-hospital mortality.

Additional Material

This paper was assessed as poor in relation to the inferences related to non-system delays. The editorial by Grines and Schreiber was fully supported. It is available here.


More ESC 2014 Papers

Thrombus aspiration RCT
FAME 2 longer term data
FAME 2 editorial

Categories: Uncategorized

Pre-hospital Ticagrelor in STEMI: ATLANTIC trial

The Atlantic trial is available here. Pre-hospital Ticagrelor was safe but did not improve primary efficacy end-point.

Categories: Uncategorized

ESC Myocardial Revascularization Guidelines

The ESC guidelines for myocardial revascularization 2014 are available here. They are comprehensive and have implications, particularly for duration of dual antiplatelet therapy post stent implantation.

Darapladib Does Not Reduce MACE in ACS (SOLID-TIMI52)

The Lipoprotein-associated phospholipase A2 (Lp-PLA2) inhibitor Darapladib did not reduce the risk of major adverse cardiac events in acute coronary syndrome. The paper is available here.

Categories: Uncategorized

Angiotensin Neprilysin Inhibition with LV Systolic Dysfunction Heart Failure

A new combination of valsartan and sacubitril (neprilysin inhibitor) has been shown to reduce from cardiovascular cause of heart failure hospitalization in patients with LV systolic dysfunction heart failure when compared with enalapril 10 mg per day. There was an increased frequency of hypotension but lower rates of renal deterioration and hyperkalemia.

Extracts from the paper are here:





The paper is availabe here.

The editorial is available here.