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.

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