Door-to-Balloon Times Improve Drastically Over 6-Year Period

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Over 90% of patients receiving primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) are now treated within the recommended 90 minutes after hospital arrival, according to a nationwide 6-year analysis of door-to-balloon (D2B) times published online August 22, 2011, ahead of print in Circulation.

Researchers led by Harlan M. Krumholz, MD, SM, of the Yale School of Medicine (New Haven, CT), analyzed improvements in D2B times by looking at Centers for Medicare and Medicaid Services (CMS) data from 301,167 STEMI patients. The patients received primary PCI from January 1, 2005, to September 30, 2010.

During the study period, median D2B times declined by 32 minutes, from 96 minutes during 2005 to 64 minutes in the year ending September 30, 2010. Over the same time interval, the percentage of patients with D2B times less than 90 minutes increased from 44.2% to 91.4% and of those achieving D2B times less than 75 minutes increased from 27.3% to 70.4%.

Patients who experienced the greatest declines in D2B times were those who had the highest median times during the initial period: elderly, women, and African-Americans (table 1).

Table 1. Median D2B Times in Patient Groups with the Greatest Declines




Patients > 75 Years of Age, min



Women, min



African-Americans, min



Hospital median D2B times also dropped over the 6-year period, from 97 minutes in 2005 to 64 minutes in 2010. As with patient groups, hospital groups that experienced the greatest reductions were those with the longest times at the beginning of the study:

  • Hospitals with 500 beds or more: decline of 34 minutes
  • For-profit hospitals: decline of 38 minutes
  • Hospitals in East South Central and Middle Atlantic census regions: declines of 40 and 35 minutes, respectively

Several national quality initiatives were credited with the sharp improvement in D2B times, including:

  • Hospital Compare: a CMS D2B reporting system
  • D2B Alliance: American College of Cardiology program to improve times
  • Mission: Lifeline: American Heart Association community STEMI care program

According to the authors, the improvement in D2B times, “experienced across the country and across different types of hospitals, represents a remarkable elevation in practice that was achieved over a relatively short period of time and in the absence of financial incentive.”

Still Work to Do

“At the beginning of these efforts, many said that this level of improvement was impossible to achieve,” Dr. Krumholz said in a press release. “This is an opportunity to reflect on our achievement and to recognize that, when we identify quality issues and problems in our health care system, we can work as a community to generate new knowledge to apply to practice and improve care for patients.”

According to ACC President David R. Holmes Jr, MD, of the Mayo Clinic (Rochester, MN), work on improving time to treatment will continue.

“We are not done. We intend to remain focused on providing training and feedback in the form of data from our registries to maintain these gains while continuing to look for ways to improve,” Dr. Holmes said in a press statement. “Another piece of the time-to-treatment equation is time lost when patients are transferred in to a referral center. Coordinated systems of care in which patients are taken directly to a hospital equipped to perform angioplasty and insert stents or are transferred quickly are crucial to continued improvement.

“It will also be critical to see how this approach affects outcomes in heart failure, reinfarction, mortality, and left ventricular function,” he added.


Krumholz HM, Herrin J, Miller LE, et al. Improvements door-to-balloon time in the United States, 2005 to 2010. Circulation. 2011;Epub ahead of print.



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  • The study was funded by CMS and the National Heart, Lung, and Blood Institute (NHLBI).
  • Dr. Krumholz reports receiving grant support from NHLBI and serving as the chair for a cardiac scientific advisory board for UnitedHealth.

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