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Original research article
Coronary intervention door-to-balloon time and outcomes in ST-elevation myocardial infarction: a meta-analysis
  1. Chee Yoong Foo1,2,3,
  2. Kwadwo Osei Bonsu3,4,5,
  3. Brahmajee K Nallamothu6,7,
  4. Christopher M Reid8,9,
  5. Teerapon Dhippayom10,
  6. Daniel D Reidpath3,11,12,13,
  7. Nathorn Chaiyakunapruk2,13,14,15
  1. 1National Clinical Research Centre, Kuala Lumpur, Malaysia
  2. 2School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia
  3. 3Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia
  4. 4Pharmacy Department, Accident and Emergency Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
  5. 5Department of Pharmacy Practice Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
  6. 6VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  7. 7Department of Internal Medicine, Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan Medical School, Ann Arbor, Michigan, USA
  8. 8School of Public Health, Curtin University, Perth, Western Australia, Australia
  9. 9School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  10. 10Faculty of Pharmaceutical Sciences, Naresuan University, Tha Pho, Muang Phitsanulok, Thailand
  11. 11School of Population Health, Curtin University, Perth, Western Australia, Australia
  12. 12Molecular, Genetic & Population Health Sciences, University of Edinburgh, Edinburgh, UK
  13. 13Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
  14. 14School of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
  15. 15Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
  1. Correspondence to Dr Nathorn Chaiyakunapruk, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Centre of Pharmaceutical Outcomes Research (CPOR), Naresuan University, Tha Pho, Phitsanulok 65000, Thailand; nui_nathorn{at}


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 timerisk 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 timerisk 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
  • meta-analysis

Statistics from


  • 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.

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