Objective This study aims to determine the relationship between door-to-balloon delay in primary percutaneous coronary intervention and ST-elevation myocardial infarction (MI) outcomes and examine for potential effect modifiers.
Methods We conducted a systematic review and meta-analysis of prospective observational studies that have investigated the relationship of door-to-balloon delay and clinical outcomes. The main outcomes include mortality and heart failure.
Results 32 studies involving 299 320 patients contained adequate data for quantitative reporting. Patients with ST-elevation MI who experienced longer (>90 min) door-to-balloon delay had a higher risk of short-term mortality (pooled OR 1.52, 95% CI 1.40 to 1.65) and medium-term to long-term mortality (pooled OR 1.53, 95% CI 1.13 to 2.06). A non-linear time–risk relation was observed (P=0.004 for non-linearity). The association between longer door-to-balloon delay and short-term mortality differed between those presented early and late after symptom onset (Cochran’s Q 3.88, P value 0.049) with a stronger relationship among those with shorter prehospital delays.
Conclusion Longer door-to-balloon delay in primary percutaneous coronary intervention for ST-elevation MI is related to higher risk of adverse outcomes. Prehospital delays modified this effect. The non-linearity of the time–risk relation might explain the lack of population effect despite an improved door-to-balloon time in the USA.
Clinical trial registration PROSPERO (CRD42015026069).
- reperfusion timeliness
- door-to-balloon time
- pre-hospital delays
- primary percutaneous coronary intervention
- myocardial infarction
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Contributors CYF and NC conceived and designed the study. CYF, NC and DDR wrote the protocol. CYF wrote the first draft. NC, DDR, BKN, CMR and TD contributed substantially to the interpretation of the data and revising the manuscript critically. CYF and KOB screened, extracted the data and performed the quality assessment. CYF has access to all the data in the study, analyses the data and takes responsibility for the integrity of the data and the accuracy of the analysis.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests BKN reported personal fees from American Heart Association, outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data used for the analyses are provided in Appendix 13. Other information—including literature searches, additional explanatory material and data extraction forms—are available on request.