Background Guidelines for ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (PPCI) within 90 min of arrival in a PCI-capable hospital. Some PCI operators perform diagnostic angiography of the non-culprit artery prior to intervention (‘non-culprit’ strategy) while others proceed directly to the presumed culprit vessel (‘culprit’ strategy) reserving imaging of the non-culprit vessel until after the PCI. We evaluated the ‘time cost’ of each approach and their impact upon door to balloon times (D2B).

Methods All consecutive patients presenting with STEMI to a regional heart attack centre between April 2014 and March 2015 (n = 630) were included. The time from the first angiogram acquisition (culprit or non-culprit vessel) to device use (thrombectomy catheter, balloon or stent) was recorded for each strategy. Overall D2B times were analysed.

Results A culprit strategy was followed in 69/630 and a non-culprit approach in 561/630. The mean time from first image to device use was 15 mins 41s for non-culprit strategy and 8 mins 9s for culprit strategy. The non-culprit strategy therefore incurred a delay of 7 mins 32s (p < 0.01). The mean D2B time was 52 mins and 66 mins for the culprit and non-culprit strategies respectively (p < 0.05). The percentage meeting D2B time <90mins was 86% for culprit and 78% for non-culprit strategies. Percentage meeting D2B time <60 mins (which may have additional mortality benefit) was 71% and 58% for the culprit and non-culprit strategies respectively. In our cohort, mortality was significantly lower in patients with D2B <90 mins at 2.0%, versus 4.6% in those whose D2B was >90mins (p = 0.02).

Conclusion A ‘culprit’ PPCI strategy results in significantly shorter D2B times, facilitating institutional attainment of national guideline targets, which may translate into improved patient outcomes.